Switching Operations Fatality Analysis 

Findings and Advisories 

of the SOFA Working Group 

Volume I: 

SOFA Report with Appendix A 

March 2011 Update 
ii

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

DEDICATION

This study is based on 179 employee fatalities involving switching operations. Appropriately, we 

dedicate this report to those who lost their lives during railroad service. While reviewing each of 

these tragic events, the SOFA Working Group (SWG) endeavored to handle each case with 

respect and dignity.

The SWG recognizes that each family will forever bear the burden of its loss. The Group 

expresses its condolences and we hope the families may gain some comfort from this report.

The goal is “Zero Fatalities” and our intent is that no other employee or family will experience 

this type of tragic event; a lesser goal is not an option. 


vi

Acknowledgments

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

ongoing support and encouragement it has received from Senior Vice President, Operations and 

Safety Robert C. VanderClute, Association of American Railroads (AAR), President Richard F. 

Timmons, American Short Line and Regional Railroad Association (ASLRRA), VP and 

National Legislative Representative John Tolman, Brotherhood of Locomotive Engineers and 

Trainmen (BLET), Administrator Joseph Szabo, of the Federal Railroad Administration (FRA), 

National Legislative Director James A. Stem, United Transportation Union (UTU). The SWG 

also acknowledges the following persons, and organizations, for their continuing support and 

dedication: 

Paul T. Sorrow and Dennis R. Pierce

National President

Brotherhood of Locomotive Engineers and Trainmen (BLET)

Jo Strang

Associate Administrator and Chief Safety Officer

Federal Railroad Administration (FRA) 

Mark E. Yachmetz

Associate Administrator for 

Office of Railroad Policy and Development

Federal Railroad Administration (FRA) 

Mike Futhey 

International President

United Transportation Union (UTU)

The present SWG expresses its appreciation to past SWG members who contributed their talents 

and energies to the SOFA process and this new report:

Danny Boyles

Georgia State Legislative Director, Retired

United Transportation Union (UTU)
vii

David Brickey

Michigan State Legislative Director, Retired

United Transportation Union (UTU)

George J. Last

Chairman, Retired

Colorado State Legislative Board

Brotherhood of Locomotive Engineers and Trainmen (BLET)

Thomas J. Perkovich

Chairman, Retired

Minnesota State Legislative Board

Brotherhood of Locomotive Engineers and Trainmen (BLET)

John P. Smullen

Minnesota State Legislative Director, past

United Transportation Union (UTU)

The SWG is grateful to the FRA Office of Research and Development for support with the 

evaluation of the implementation issues related to the SOFA findings. In particular, the following 

persons provided expertise during the evaluation efforts: Michael Patton, Ph.D. (UtilizationFocused Evaluation), Debbie Bonnet (Fulcrum Corporation), and Joyce Ranney, Ph.D.

(VNTSC). Also, the SWG thanks Margaret Kondracki and Lauren Alexander (Fulcrum 

Corporation); Hadar Rosenhand, Cathy Guthy, and Stephanie Morrow, Ph.D. (VNTSC); and 

Aaron Thompson (FRA) for their supportive work.

The SWG also acknowledges the efforts of the railroads and labor unions within the railroad 

industry for their participation during the SOFA Safety Forum of February 2010. Their 

attendance and input was extremely beneficial to the success of this report.
viii

Table of Contents

EXECUTIVE SUMMARY ..................................................................................................................................XVII

ES 1 INTRODUCTION..................................................................................................................................XVII

ES 1.1........................................................................................................................................................... PURPOSE

XVII

ES 1.2...................................................................................................................................................BACKGROUND

XVII

ES 1.2.1 History of Switching Fatalities......................................................................................................xvii

ES 2 SOFA PROCESS.................................................................................................................................. XVIII

ES 2.1............................................................................................................................................ SIX STEP PROCESS

XVIII

ES 3 SWITCHING FATALITIES – UNDERSTANDING AND PREVENTION................................... XVIII

ES 3.1........................................................................................................................................................ OVERVIEW

XVIII

ES 3.2................................................................................................SUBSTANTIAL PROGRESS ON SOFA 1, 2, AND 4

XX

ES 3.3....................................... NO SUBSTANTIAL PROGRESS ON SOFA 3 (LACK OF OR INADEQUATE JOB BRIEFING)

XX

ES 3.3.1 Briefings - Job or Safety (SOFA3) – SOFA Safety Advisory Statement 2010 ................................. xx

ES 3.4................................................ LITTLE PROGRESS ON SOFA 5 (EMPLOYEES WITH 1.5 YEARS OF EXPERIENCE)

XXI

ES 3.4.1 Inexperienced Employee (SOFA5) – SOFA Safety Advisory Statement 2010................................ xxi

ES 3.5................................................................................................... CLOSE/NO CLEARANCE – A GROWING ISSUE

XXI

ES 3.5.1 Close Clearance – SOFA Safety Advisory Statement 2010............................................................ xxi

ES 3.6........................................................................................... INDUSTRIAL TRACK HAZARD - A GROWING ISSUE

XXI

ES 3.6.1 Industrial Hazards – SOFA Safety Advisory Statement 2010 ........................................................ xxi

ES 3.7.........................................................................................STRUCK BY MAINLINE TRAINS - A GROWING ISSUE

XXII

ES 3.7.1 Struck By Mainline Train – SOFA Safety Advisory Statement 2010.............................................xxii

ES 3.8............................................................................................FATALITIES DURING THE SECOND HOUR OF DUTY

XXII

ES 4 ADDITTIONAL SUGGESTED ACTIONS....................................................................................... XXIII

ES 4.1......................................................................................................................EMPOWERMENT AND DISCIPLINE

XXIII

ES 4.2........................................TRANSITION THE SWG FROM “ANALYSIS” TO “ANALYSIS AND IMPLEMENTATION”

XXIII

ES 4.3................................................................................................................CONDUCT ANNUAL SWG MEETINGS

XXIII

ES 5 ADDITIONAL INFORMATION ....................................................................................................... XXIII

1 INTRODUCTION..............................................................................................................................................1

1.1 PURPOSE ..........................................................................................................................................................1

1.2 BACKGROUND..................................................................................................................................................1

1.2.1 Origin and Past Efforts of the SOFA Working Group ...........................................................................1

1.2.2 History of Switching Fatalities ..............................................................................................................2
ix

1.2.3 Operating Recommendations and the Five Lifesavers...........................................................................2

1.2.4 Additional Recommendations, October 1999 SOFA Report..................................................................3

1.2.5 August 2004 SOFA Update....................................................................................................................3

1.2.6 Close Clearance.....................................................................................................................................4

2 SOFA PROCESS................................................................................................................................................6

2.1 INTRODUCTION ................................................................................................................................................6

2.2 CASE SELECTION .............................................................................................................................................6

2.3 CASE REVIEW ..................................................................................................................................................6

2.3.1 Presentation...........................................................................................................................................6

2.3.2 Recording the Facts...............................................................................................................................7

2.3.3 Case Discussions...................................................................................................................................7

2.3.4 Agreement on Possible Factors.............................................................................................................7

2.4 CLASSIFICATION OF THE CASES .......................................................................................................................7

2.4.1 October 1999 SOFA Report...................................................................................................................8

2.4.2 August 2004 SOFA Update....................................................................................................................8

2.4.3 December 2010 Update .........................................................................................................................9

2.5 ANALYSIS – SEARCHING FOR COMMONALITIES ...............................................................................................9

2.6 IDENTIFICATION OF PRELIMINARY FINDINGS .................................................................................................10

2.7 DEVELOPMENT OF FINDINGS..........................................................................................................................10

2.8 SOFA DATABASE ..........................................................................................................................................11

2.9 ASSUMPTIONS AND LIMITATIONS...................................................................................................................11

3 SWITCHING FATALITIES – UNDERSTANDING AND PREVENTION ..............................................13

3.1 OVERVIEW .....................................................................................................................................................13

3.2 SUBSTANTIAL PROGRESSION SOFA 1, 2, AND 4.............................................................................................15

3.2.1 Finding.................................................................................................................................................15

3.2.2 Discussion............................................................................................................................................18

3.2.3 Conclusion ...........................................................................................................................................18

3.3 NO SUBSTANTIAL PROGRESS ON SOFA 3 (LACK OF OR INADEQUATE JOB BRIEFING) ....................................18

3.3.1 Finding.................................................................................................................................................18

3.3.2 Background..........................................................................................................................................19

3.3.3 Statistical Background.........................................................................................................................19

3.3.4 Discussion ............................................................................................................................................20

3.3.5 Briefings – Job or Safety (SOFA 3) – SOFA Safety Advisory Statement 2010 ..............................202

3.4 LITTLE PROGRESS ON SOFA 5 (EMPLOYEES WITH 1.5 YEARS OF EXPERIENCE) ............................................22

3.4.1 Finding.................................................................................................................................................22

3.4.2 Background..........................................................................................................................................23

3.4.3 Statistical Background.........................................................................................................................25

3.4.4 Inexperienced Employee (SOFA 5) – SOFA Safety Advisory Statement 2010.................................27

3.5 CLOSE/NO CLEARANCE – A GROWING ISSUE ................................................................................................27

3.5.1 Finding.................................................................................................................................................27

3.5.2 Background..........................................................................................................................................28

3.5.3 Definitions ...........................................................................................................................................28

3.5.4 Statistical Background.........................................................................................................................31

3.5.5 Discussion............................................................................................................................................31

3.5.6 Close Clearances – SOFA Safety Advisory Statement 2010..............................................................32

3.6 INDUSTRIAL TRACK HAZARD – A GROWING ISSUE........................................................................................33

3.6.1 Finding.................................................................................................................................................33

3.6.2 Background..........................................................................................................................................33

3.6.3 Statistical Background.........................................................................................................................35

3.6.4 Discussion............................................................................................................................................35

3.6.5 Industrial Hazards – SOFA Safety Advisory Statement 2010 ...........................................................37
x

3.7 STRUCK BY MAINLINE TRAINS – A GROWING ISSUE......................................................................................38

3.7.1 Finding.................................................................................................................................................38

3.7.2 Background..........................................................................................................................................38

3.7.3 Statistical Background.........................................................................................................................39

3.7.4 Discussion............................................................................................................................................40

3.7.5 Struck by Mainline Train – SOFA Safety Advisory Statement 2010 ................................................42

3.8 FATALITIES DURING THE SECOND HOUR OF DUTY ........................................................................................43

3.8.1 Finding.................................................................................................................................................43

3.8.2 Background..........................................................................................................................................44

3.8.3 Statistical Background.........................................................................................................................44

3.8.4 Discussion............................................................................................................................................45

3.8.5 Conclusion ...........................................................................................................................................45
xi

4 NOTABLE STATISTICS AND OBSERVATIONS......................................................................................46

4.1 INTRODUCTION ..............................................................................................................................................46

4.2 CLASSIFICATION OF SOFA CASES .................................................................................................................46

4.2.1 Most Frequent PCFs............................................................................................................................46

4.3 TYPE OF TRACK .............................................................................................................................................47

4.4 TYPE OF MOVEMENT......................................................................................................................................48

4.5 FE’S LOCATION .............................................................................................................................................48

4.6 FE AGE AND EXPERIENCE..............................................................................................................................49

4.7 FATALITIES IN COLD WEATHER STATES DURING WINTER AND OTHER STATES DURING SUMMER ...............49

HIGH RISK HOLIDAY PERIODS .......................................................................................................................51

4.8 51

5 SOFA-DEFINED SEVERE INJURIES .........................................................................................................53

5.1 INTRODUCTION

5.1.1 Chapter Overview................................................................................................................................53

5.2 IMPORTANCE OF SEVERE INJURIES.................................................................................................................53

5.3 DEFINITION OF SOFA-DEFINED SEVERE INJURIES .........................................................................................54

5.4 SOFA INTEREST IN SEVERE INJURIES ............................................................................................................55

5.5 INFORMATION DIFFICULTIES IN DETERMINING CAUSES OF SOFA-DEFINED SEVERE INJURIES ......................56

5.6 DECLINES IN SOFA-DEFINED SEVERE INJURIES.............................................................................................56

5.7 SEASONALITY AND WINTER MONTHS............................................................................................................58

5.7.1 Cluster of Slipped, Fell, Stumbled, etc., Injury Types...Increases in winter Months...........................59

5.8 GOING FORWARD...........................................................................................................................................60

6 EVALUATION OF THE SOFA WORKING GROUP FOR THE IMPLEMENTATION OF SOFA 

FINDINGS..................................................................................................................................................................61

6.1 INTRODUCTION ..............................................................................................................................................61

6.2 EVALUATION GOALS......................................................................................................................................61

6.3 BACKGROUND................................................................................................................................................61

6.4 EVALUATION STANDARDS .............................................................................................................................62

6.5 EVALUATION APPROACH, METHOD, & PHASES .............................................................................................63

6.5.1 Document Analysis of Past Implementation Strategies........................................................................63

6.5.2 Logic Modeling of SWG Theory of Action...........................................................................................65

6.5.3 Process Evaluation ..............................................................................................................................66

6.5.4 SWG Interviews ...................................................................................................................................67

6.5.5 SOFA Working Group Reunion ...........................................................................................................68

6.5.6 SOFA Safety Forum.............................................................................................................................68

6.6 CONCLUSION..................................................................................................................................................71

7 ADDITIONAL SUGGESTED ACTIONS .....................................................................................................72

7.1 INTRODUCTION ..............................................................................................................................................72

7.2 EMPOWERMENT AND DISCIPLINE ...................................................................................................................72

7.3 FRA FATALITY INVESTIGATION PROCESS AND DATA COLLECTION...............................................................72

7.4 SWG IMPROVEMENTS....................................................................................................................................72

7.4.1 Transition the SWG From “Analysis” to “Analysis and Implementation” .........................................72

7.4.2 Conduct Annual SWG Meetings...........................................................................................................72

7.4.3 Improve the SOFA Database ...............................................................................................................73
xii

List of Figures

FIGURE ES-1 SWITCHING FATALITIES .......................................................................................................................XVII

FIGURE ES-2 SOFA FATALITIES ................................................................................................................................ XIX

FIGURE ES-3 FATALITIES FOR SOFA 1, SOFA 2, AND SOFA 4 .................................................................................. XX

FIGURE 1-1. SWITCHING FATALITIES, 1975 THROUGH 2009...........................................................................................2

FIGURE 2-1 AUGUST 2004 UPDATE ................................................................................................................................8

FIGURE 3-1: SOFA FATALITIES BY YEAR ....................................................................................................................13

FIGURE 3-2: SOFA FATALITIES IN SIX AREAS .............................................................................................................14

FIGURE 3-3: FATALITIES FOR SOFA 1, SOFA 2, AND SOFA 4.....................................................................................15

FIGURE 3-4: SOFA 3 FATALITIES OVER TWO NINE-YEAR PERIODS ............................................................................18

FIGURE 3-5: SOFA 5 FATALITIES OVER TWO NINE-YEAR PERIODS ............................................................................22

FIGURE 3-6: SSH CLOSE/NO CLEARANCE FATALITIES OVER TWO NINE-YEAR PERIODS ............................................27

FIGURE 3-7: SPECIAL SWITCHING HAZARD INDUSTRIAL TRACK HAZARD OVER TWO NINE-YEAR PERIODS...............33

FIGURE 3-8: SPECIAL SWITCHING HAZARD STRUCK BY MAINLINE TRAINS OVER TWO NINE-YEAR PERIODS ............38

FIGURE 3-9: HOURS ON DUTY BEFORE INCIDENT.........................................................................................................43

FIGURE 3-10: FATALITIES DURING THE SECOND HOUR OF DUTY OVER TWO NINE-YEAR PERIODS ............................43

FIGURE 4-1: SOFA FATALITIES BY TRACK TYPE .........................................................................................................47

FIGURE 4-2: SOFA FATALITIES BY LOCATION .............................................................................................................48

FIGURE 4-3: AGE AND EXPERIENCE..............................................................................................................................49

FIGURE 4-4: SOFA FATALITIES BY MONTH.................................................................................................................49

FIGURE 4-5: SOFA FATALITIES BY MONTH FOR COLD-WEATHER STATES .................................................................50

FIGURE 4-6: SOFA FATALITIES BY MONTH FOR OTHER (NON-COLD-WEATHER) STATES..........................................51

FIGURE 5-1: SOFA-DEFINED SEVERE INJURIES BY YEAR, 1997 THROUGH OCTOBER 2010 ..........................................53

FIGURE 5-2: SOFA-DEFINED SEVERE INJURIES V. ALL REPORTABLE CASUALTY (BUT NOT DEATHS), TY&E

EMPLOYEES, 1997 THROUGH 2009......................................................................................................................57

FIGURE 5-3: SOFA-DEFINED SEVERE INJURIES, BY MONTH, 1997 THROUGH 2009.......................................................58
xiii

List of Tables

TABLE ES-1: THE MOST PROMINENT SOFA CATEGORIES......................................................................................... XIX

TABLE 2-1: THE 15 SSH CLASSIFICATIONS USED BY THE SWG....................................................................................9

TABLE 3-1: SOFA CATEGORIES WITH THE MOST FATALITIES .....................................................................................15

TABLE 3-2: CASE NUMBERS FOR SOFA 1, 2, AND 4 .....................................................................................................17

TABLE 3-3: TWENTY-THREE CASES OF SOFA 3...........................................................................................................20

TABLE 3-4: 32 SOFA 5 CASES .....................................................................................................................................24

TABLE 3-5: SOFA 5 CASES INVOLVING A SHOVE MOVE – ALL RAILROADS FAILURE TO CONTROL THE SHOVE.........25

TABLE 3-6 SURVIVING INEXPERIENCED CREW MEMBER..............................................................................................25

TABLE 3-7: SOFA 5 CASES - REGIONAL AND SHORT LINE RAILROADS .......................................................................25

TABLE 3-8: SOFA 5 CASES – CLASS I RAILROADS.......................................................................................................25

TABLE 3-9: 29 CASES INVOLVING CLOSE/NO CLEARANCE ..........................................................................................30

TABLE 3-10: TYPE OF CLEARANCE AND TRACK...........................................................................................................31

TABLE 3-11: CLOSE/NO CLEARANCE INDUSTRY TRACK CASES...................................................................................31

TABLE 3-12: CLOSE/NO CLEARANCE DERAILMENT CASES..........................................................................................31

TABLE 3-13: 26 CASES INVOLVING INDUSTRIAL TRACK HAZARDS..............................................................................34

TABLE 3-14: INDUSTRIAL TRACK HAZARD CLOSE/NO CLEARANCE ............................................................................35

TABLE 3-15: INDUSTRIAL TRACK HAZARD DERAILMENTS...........................................................................................35

TABLE 3-16: INDUSTRIAL TRACK HAZARD MOTOR VEHICLES (STRUCK BY) ..............................................................35

TABLE 3-17 - 20 CASES FOR EMPLOYEES STRUCK BY MAINLINE TRAINS ...................................................................39

TABLE 3-18 STRUCK BY MAINLINE TRAINS - DARK.....................................................................................................40

TABLE 3-19 STRUCK BY MAINLINE TRAINS DURING DEC, JAN, AND FEB ....................................................................40

TABLE 3-20: CASE NUMBERS FOR FATALITIES DURING THE SECOND HOUR OF DUTY ................................................44

TABLE 3-21: 2ND HOUR OF DUTY, YARD TRACK...........................................................................................................45

TABLE 3-22: 2ND HOUR OF DUTY, FE ON THE GROUND ................................................................................................45

TABLE 4-1: CLASSIFICATION OF SOFA CASES .............................................................................................................46

TABLE 4-2: MOST FREQUENTLY USED PCFS...............................................................................................................47

TABLE 4-3: SOFA FATALITIES BY TYPE OF MOVEMENT..............................................................................................48

TABLE 4-4: FATALITIES IN COLD-WEATHER STATES ...................................................................................................50

TABLE 4-5: FATALITIES IN OTHER (NON-COLD-WEATHER) STATES............................................................................51

TABLE 4-6: SOFA FATALITIES DURING THE FOUR HIGH-RISK WEEKS........................................................................52

TABLE 5-1: DEFINITION OF SOFA-DEFINED SEVERE INJURIES .....................................................................................54

TABLE 5-2: SOFA-DEFINED SEVERE INJURIES BY NATURE OF INJURY, 1997 THROUGH 2009......................................55

TABLE 5-3: SOFA-DEFINED SEVERE INJURIES AS PERCENTAGE OF ALL REPORTABLE CASUALTY TO TRAIN AND 

ENGINE SERVICE EMPLOYEES, 1997 THROUGH 2009..........................................................................................57

TABLE 6-1 KEY EVALUATION EVENTS TIMELINE WITH THE SWG...............................................................................63

TABLE 6-2: 2000-01 REPORTED IMPLEMENTATION ACTIVITIES RELATED TO THE SOFA RECOMMENDATIONS...........64

TABLE 6-3 SOFA SAFETY FORUM (SSF) ATTENDEE AFFILIATION LIST ......................................................................69

TABLE 6-4: SSF THEMES BY SOFA KEY FINDING .......................................................................................................70
xiv

Appendices

APPENDIX A: SOFA Cases 1992 - 2009

Volume I

APPENDIX B: SOFA TASKING LETTER

Volume II

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
xv

List of Abbreviations and Terms

ABBREVIATIONS

CRM: Crew Resource Management 

FE: In the October 1999 SOFA Report, FE meant “fatality of an employee.” Sometimes,

it is used also to mean “fatally injured employee.”

PCF: Possible Contributing Factor

RCL: Remote Controlled Locomotives

SOFA: Switching Operations Fatality Analysis 

SSF: SOFA Safety Forum (February 2010)

SSH: Special Switching Hazard

SSH-CC: Special Switching Hazard – Close Clearance; a frequently occurring SSH

SSH-IH: Special Switching Hazard – Industrial Hazard; a frequently occurring SSH

SSH-ST: Special Switching Hazard – Struck by Mainline Train; a frequently occurring SSH

SWG: SOFA Working Group

TY&E: Train, Yard, and Engine 

TERMS

Five Operating Recommendations: In its 1999 SOFA Report, the SWG made Five Operating 

Recommendations. The Five Operating Recommendations are shown in Appendix C. 

Five Life Savers: After release of the 1999 SOFA Report, the SWG developed condensed 

versions of the Five Operating Recommendations. These shortened versions came to be known 

as the Five Lifesavers.

Railroad Industry: The combination of railroad management, labor, and government agencies

conducting regulated railroad operations.

SOFA 1-5 Categories: In the 1999 SOFA Report, the SWG looked at 76 SOFA fatalities from 

January 1992-June 1998 and classified them into five different categories corresponding to the 

Five Operating Recommendations. For this report, we call these categories SOFA 1-5.

Special Switching Hazards: Beyond the five categories for SOFA 1-5, the SWG used fifteen 

categories corresponding to Special Switching Hazards (SSH) to classify cases. SSH applies to 

hazards which are not covered the original SOFA 1-5 categories. These SSH categories are 

shown in Table 2-1.

Possible Contributing Factors: The SWG conducted intense discussions of each case until there 

was an agreement on possible factors. The SWG used an approach to define possible factors 

based on consideration of a complex combination of operating characteristics, conditions, and 

events. The SWG did not attempt to rank these factors. Table 4-2 shows the most frequently used 

PCFs. Appendix E provides a full list of the PCFs used by the SWG.
xvi

Types of Close/No Clearance:

o No Clearance: Insufficient space for the employee to avoid being struck if passing 

or being passed by an object, structure, or equipment.

o Close Clearance: Insufficient space for the employee to take evasive action to 

avoid being struck by moving equipment that derails into an object, structure, or 

other equipment.

o Permanent Close/No Clearance: A fixed structure that remains in the same 

location from day to day, such as a building, loading dock, fence, post, beam, or 

other permanent structure, that an employee passes.

o Temporary Close/No Clearance: A movable object, including equipment on or 

near one track fouling another track, rolling stock on an adjacent track, stacks of 

cross ties, construction materials, and doors or gates left open, that passes by an 

employee or an employee passes.
xvii

EXECUTIVE SUMMARY

ES 1 INTRODUCTION

ES 1.1 Purpose

In support of achieving the Switching Operations Fatality Analysis (SOFA) goal of Zero 

Switching Fatalities, the purpose of this report is to:

o Present the analysis and findings of the SOFA Working Group (SWG) to the 

railroad industry.

o Offer ideas on improving the safety of Train, Yard, and Engine (TY&E) 

employees performing switching operations.

o Encourage implementation of improved safety practices with the cooperation of 

government, labor, and management.

ES 1.2 Background

The SWG was formed in 1998 and is made up of representatives from the Association of 

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

(ASLRRA), Brotherhood of Locomotive Engineers and Trainmen (BLET), Federal Railroad 

Administration (FRA), and United Transportation Union (UTU). The SWG has issued two major 

reports before this one. The first was the 1999 SOFA Report. Based on a review of 76 fatalities, 

this report made Five Operating Recommendations which were subsequently summarized into 

the Five SOFA Lifesavers. The second report, the 2004 SOFA Update, included a review of an 

additional 48 switching fatalities and brought the total number of cases reviewed up from 76 to 

124. This update also identified Special Switching Hazards (SSH) that were not necessarily 

preventable by one or more of the original Five Operating Recommendations.

ES 1.2.1 History of Switching Fatalities

Figure ES-1 Switching Fatalities
xviii

ES 2 SOFA PROCESS

ES 2.1 Six Step Process

1. Case Selection: The selection criteria are all fatalities from 2004 through 2009 involving 

Train, Yard, and Engine (TY&E) employees who were: 

o Fatally injured while on the ground.

o Fatally injured while riding on the outside of train equipment.

2. Case Review: The SWG followed four principle steps in reviewing a case: 1) Case 

presentation, 2) Recording the facts into a database, 3) Discussion, and 4) Agreement on 

one or more as Possible Contributing Factors (PCFs).

3. Classification of Cases: After review of all cases, the SWG classified the cases into one or 

more of the SOFA 1-5 categories. A case could also qualify for one or more of 15 different 

SSH categories.

4. Analysis – Searching for Commonalities: After case classification, the process of 

discovering ‘commonalities’ began. Commonalities, as used in this report, are shared 

characteristics among cases that may lead to a common solution.

5. Identification of Preliminary Findings: The SWG, based on the consensus of its members, 

developed preliminary findings. The SWG hosted a SOFA Safety Forum (SSF) with senior 

leaders in the railroad industry to participate in the further development of these findings 

and to increase SOFA awareness.

6. Development of Findings: The SWG used various ideas from the SSF and contributed its 

own thoughts to complete development of the findings.

ES 3 SWITCHING FATALITIES – UNDERSTANDING AND 

PREVENTION 

ES 3.1 Overview

The SOFA Working Group (SWG) has reviewed 179 switching fatality cases from 1992 through 

2009, an 18-year period. Figure ES-2 shows a year-by-year graph of those fatalities. There is a 

line in the middle of Figure ES-2 which divides the graph into two nine-year periods: the period 

from 1992 through 2000 and the period from 2001 through 2009.
xix

Figure ES-2 SOFA Fatalities

The SWG believes 2001 was the first year that the 1999 SOFA Report could have had full effect 

on reducing fatalities. That means one way to interpret Figure 3-1 is to regard the first nine-year 

period (1992 – 2000) as the Pre-SOFA period and the second nine-year period (2001 – 2009) as 

the Post-SOFA period.

The average number of cases in the Pre-SOFA period is 11.1. During the next 9 years, the PostSOFA period, the average number of cases dropped to 8.8, about a 21% reduction. Therefore, the 

railroad industry achieved some success in reducing SOFA fatalities since the first efforts to raise 

SOFA awareness. Table ES-1 shows the most prominent SOFA categories with the number of 

fatalities for the Pre and Post-SOFA periods.

Table ES-1: The Most Prominent SOFA Categories 

SOFA 

Category Description

Pre-SOFA 

(1992-2000)

Post-SOFA 

(2001-2009) Total

SOFA5 FE had 1.5 years of experience or less or had inadequate training. 17 15 32

SSHCC Special Switching Hazard: Close Clearance. 11 18 29

SSHIH Special Switching Hazard: Industrial Hazard. 10 16 26

SOFA3 Lack of or inadequate job safety briefing. 11 12 23

SOFA1 Adjusting knuckles, adjusting drawbars, or installing EOT 15 6 21

SOFA4 Mixing hand and radio signals or specific distances were not given. 17 3 20

SSHST Special Switching Hazard: Struck by Mainline Train. 7 13 20
xx

ES 3.2 Substantial Progress on SOFA 1, 2, and 4

Figure ES-3 shows a paired bar chart displaying the number of SOFA 1, 2, and 4 fatalities over 

two nine-year periods (Pre-SOFA versus Post-SOFA).

Figure ES-3 Fatalities for SOFA 1, SOFA 2, and SOFA 4 

The paired bars for each case show an impressive reduction for SOFA 1, 2, and 4. SOFA 1 

fatalities are down 60% from in the Pre-SOFA period to the 6 fatalities in the Post-SOFA period.

SOFA 2 fatalities have declined 70% from 10 in the Pre-SOFA period to 3 in the Post SOFA 

period. The biggest improvement is in SOFA 4 where there has been a decline of over 80% from 

17 fatalities in the Pre-SOFA period to 3 in the Post-SOFA period.

Operating Recommendations 1, 2, and 4 had a structure that highlighted pre-existing, procedural 

safety rules where compliance with the rules could be observed. This structure enabled the 

railroad industry to monitor the tasks associated with these operating recommendations and take 

corrective action when necessary.

ES 3.3 No Substantial Progress on SOFA 3 (Lack of or inadequate job briefing)

SOFA 3 is the fourth largest category of SOFA fatalities. Table ES-1 on the previous page shows

there has been no substantial progress on reducing SOFA 3 fatalities from the Pre-SOFA to the 

Post-SOFA periods.

ES 3.3.1 Briefings - Job or Safety (SOFA3) – SOFA Safety Advisory Statement 2010

The SWG believes ongoing communication is crucial among employees during the entire time 

switching operations are being performed, including periods when tasks are changing or when 

anomalies occur. A job briefing is a two-way exchange of information to reach an understanding 

of the tasks being performed.

Despite considerable efforts within the railroad industry, more than half of SOFA 3 fatalities in 

yards and industrial properties occurred when a job task changed and an update to the job 

briefing did not occur. The SWG believes more progress can be made in the area of work 

changes. When work changes occur, the employees involved may not maintain currency with 

these changes; thus, they may be unaware of the tasks to be performed, and this may place them 

in peril. The railroad industry must remain vigilant regarding fatalities, and when work changes 

Fatalities For SOFA 1, SOFA 2, And SOFA 4

0

2

4

6

8

10

12

14

16

18

Pre-SOFA (1992 - 2000) 15 10 17

Post-SOFA (2001 - 2009) 6 3 3

SOFA1 SOFA2 SOFA4
xxi

occur, employees must regroup, take appropriate steps to provide protection, and not proceed 

until an update to the job briefing is done.

ES 3.4 Little Progress on SOFA 5 (Employees with 1.5 years of experience)

With 32 cases, SOFA 5 is the largest category of SOFA fatalities. Table ES-1 shows there has 

been little progress on reducing SOFA 5 fatalities from the Pre-SOFA to the Post-SOFA periods.

ES 3.4.1 Inexperienced Employee (SOFA5) – SOFA Safety Advisory Statement 2010

Since the 1999 Report, the SWG emphasis on mentoring has not achieved a substantial reduction 

in SOFA 5 fatalities. It is critical for the railroad industry to provide the inexperienced employee 

adequate OJT. Without abandoning the commitment to mentoring, the railroad industry should 

improve OJT to include targeted training for the inexperienced employee. Providing follow-up 

review of skills, and targeted training by the railroad industry enables an inexperienced employee 

to meet the demands of the job. Smaller railroads in particular may benefit from a review of their 

OJT, and improved follow-up with inexperienced employees.

ES 3.5 Close/No Clearance – A Growing Issue

Close/No clearance is the second largest category of SOFA fatalities. Table ES-1 shows fatalities 

involving close/no clearances have increased from the Pre-SOFA to the Post-SOFA periods.

ES 3.5.1 Close Clearance – SOFA Safety Advisory Statement 2010

The SWG reemphasizes that removing the hazard is the best way to address close/no clearances. 

Yet, in many cases a railroad or industry will not be able to eliminate the close/no clearance 

condition. At the minimum, the SWG believes that proper signage should be implemented and be 

instructive to the employee. Additionally, the sign should be an appropriate distance from the 

close/no clearance location and on the same side. Signage must (a) announce the clearance issue 

and (b) instruct the employee who is controlling the movement to dismount and remain 

dismounted from the equipment while passing the close/no clearance location. One method to 

determine the signage design, appropriate distance, and position may be to organize a 

management-labor working group.

ES 3.6 Industrial Track Hazard - A Growing Issue

Industrial Track Hazard is the third largest category of SOFA fatalities. Table ES-1 shows 

fatalities involving industrial track hazards have increased from the Pre-SOFA to the Post-SOFA 

periods.

ES 3.6.1 Industrial Hazards – SOFA Safety Advisory Statement 2010

Railroads and industries need to have Industry Track Agreements, practices, or policies in place, 

and these should contain oversight and enforcement of the safety provisions. Railroads must 

provide employees with the tools and/or assistance to allow them to safely perform their work 

while within an industry.

Employees need to be empowered to make a decision to stop work when an unsafe condition 

presents itself. Railroad managers must be educated to encourage employees to make a good 

faith effort to identify and report hazards at industries. Employees making a good faith effort to 
xxii

identify and report hazards will not be subject to discipline, discrimination, or harassment for 

doing so.

Employees engaged in switching operations must not ride railroad equipment through a grade 

crossing during a shove movement. Industries need to educate and instruct all vehicle operators 

concerning separation between their vehicle and railroad equipment by being attentive to 

movements in the industry. At the minimum, the SWG believes that proper education and 

instruction should be implemented by the industry. Additionally, signage and lighting should be

appropriate for the crossing protection needed.

ES 3.7 Struck By Mainline Trains - A Growing Issue

Struck by Mainline Trains is tied for the sixth category of SOFA fatalities. Table ES-1 shows 

fatalities involving TY&E employees who are struck by mainline trains have increased from the 

Pre-SOFA to the Post-SOFA periods.

ES 3.7.1 Struck By Mainline Train – SOFA Safety Advisory Statement 2010

The SWG reemphasizes that communication is essential to eliminating fatalities related to Struck 

by Mainline Trains. Fatalities occur when employees are unaware of risks associated with doing 

work along mainline track – particularly at times of darkness and during winter months. 

Therefore, the railroad industry should insist upon consistent use of multiple methods to warn 

employees about oncoming on-track movements. Equally, warnings should be made to the 

approaching on-track movement of an employee’s location when a crew member is outside of 

the locomotive cab. In addition, the railroad industry should consider improving employee 

visibility when performing work on the ground.

Employees must use job briefing procedures before dismounting the locomotive or doing work 

along mainline track to establish a safe method for performing their work. When possible, 

employees must dismount to the safe side. Empower employees to establish a safe location

when stopping and/or performing work when on or near mainline track. The railroad industry 

must support employees in the use of individual discretion as part of an effort to determine a safe 

location to perform work.

ES 3.8 Fatalities during the Second Hour of Duty

The number of SOFA fatalities during the second hour of duty is higher than any other on-duty 

hour. The number of fatalities (30) occurring during the second hour of duty is surpassed by only 

one SOFA category, SOFA 5. Therefore, the industry should develop safety campaigns and other 

safety-related measures to make the workforce aware of this issue and will lead to the 

elimination of second hour of duty fatalities. 
xxiii

ES 4 ADDITTIONAL SUGGESTED ACTIONS

ES 4.1 Empowerment and Discipline

Safe practices in switching operations are the responsibility of all railroad industry employees.

Employees must be able to make decisions on safe actions and be allowed to cease work in the 

interest of safety. As expressed in many of the railroad’s empowerment statements, when 

performing safe actions employees should be free from reprisal by discipline, discrimination, or 

harassment when executing those safe actions. When using discretion to choose safe actions, the 

employee should use that discretion appropriately. An empowered work environment allows the 

railroad industry to progress toward attaining the SOFA goal of Zero Fatalities

ES 4.2 Transition the SWG From “Analysis” to “Analysis and Implementation”

The initial SOFA tasking letters called for a task force (later named the SWG) to conduct an 

analysis of switching fatalities. Since the role of the SWG in promoting implementation is not 

clear in these letters, the SWG has focused on analysis of fatalities. However, the SWG is not 

fully satisfied with the effect of the first two reports in terms of implementation and reduction in 

switching fatalities. To make this and future reports more successful, the SWG needs to expand 

its role further in the implementation phase. SWG duties should not end upon issuance of this 

report, and continued stakeholder support throughout the implementation phase is essential.

ES 4.3 Conduct Annual SWG Meetings

For this report, the SWG has met from January 2009 to December 2010. The frequency of 

meetings during this period (about once every month) made substantial demands on the members 

and their sponsoring organizations. After this report, the SWG recommends meeting three to four 

times a year to review current cases if needed, to monitor and identify trends, and to track the 

progress of industry implementation efforts. Reports and updates may not be issued every year.

Instead, they would be issued if necessary in response to any emerging trends that demand 

action.

ES 5 ADDITIONAL INFORMATION

Not all SOFA chapters are fully described in this Executive Summary but further information 

about areas of interest can be found in the following chapter locations:

• Chapter 4 – Notable Statistics and Observations

• Chapter 5 – SOFA-Defined Severe Injuries (Including definition of same)

• Chapter 6 – Evaluation of the SOFA Working Group for the Implementation of SOFA 

Findings

• Appendix A: SOFA 2010 Report (Summaries of 179 SOFA Fatalities Cases)
1

1 INTRODUCTION

1.1 Purpose

In support of achieving the Switching Operations Fatality Analysis (SOFA) goal of Zero 

Switching Fatalities, the purpose of this report is to:

1. Present the analysis and findings of the SOFA Working Group (SWG) to the railroad 

industry.

2. Offer ideas on improving the safety of Train, Yard, and Engine (TY&E) employees 

performing switching operations.

3. Encourage implementation of improved safety practices with the cooperation of government, 

labor, and management.

1.2 Background

1.2.1 Origin and Past Efforts of the SOFA Working Group

In February 1998, George A. Gavalla, Associate Administrator for Safety of the FRA, charged 

the SWG to: “Conduct a detailed fact-finding review and analysis of these incidents [switching 

fatalities] to determine whether trends or patterns can be found, identify best practices, and, if 

possible, formulate recommendations for the entire railroad industry based on the findings.” 

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

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

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

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

Railroad Administration (FRA), and United Transportation Union (UTU).

The SWG has undertaken a number of activities since the release of its SOFA Report: Findings 

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

the review of 76 fatalities that occurred to TY&E employees engaged in switching operations 

from January 1, 1992 through July 1, 1998. 

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

These activities include:

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

Recommendations made in the 1999 SOFA Report; 

• Publishing a SOFA Update in August 2004 that included a review of the 48 switching 

fatalities that occurred from August 1998 through December 2003. This update brought 

the total number of cases reviewed up from 76 to 124. More details on this update are 

provided below;

• Identifying Special Switching Hazards (SSH) such as close clearance and being struck by 

mainline trains that resulted in switching fatalities that were not necessarily preventable 

by one or more of the original Five Operating Recommendations;
2

• Studying severe injuries, such as amputations, that cause harm to employees performing

switching operations and publicizing information about the number and types of 

switching fatalities and severe injuries.

In serving as an update, this 2010 report describes SWG activities. These activities are important 

because from January 2004 through December 2009, there have been 55 switching fatalities not 

covered in the SOFA Update, August 2004.

1.2.2 History of Switching Fatalities

The SWG switching fatality review dates back to 1975. From 1975 through 1982, fatalities 

averaged 31.2 per year, far higher than in the years following. After 1982, fatalities began to 

decline, moving within a range of 7 to 15 per year through year 2000. During this period, the 

average fatalities-per-year was 10.8. 2001 was the first year that the SWG’s recommendations

could have resulted in noticeable change. From 2001 through 20091, fatalities moved within in a 

range of 6 to 12 per year, averaging 8.8 fatalities-per-year. Although there has been some 

improvement, the need for immediate, preventive action is still urgent. Figure 1-1 provides a line

chart that shows the number of switching fatalities from 1975 through 2009.

Figure 1-1. Switching Fatalities, 1975 through 2009

1.2.3 Operating Recommendations and the Five Lifesavers

In its 1999 SOFA Report, the SWG made Five Operating Recommendations based on review of 

76 fatality cases occurring from January 1, 1992 through July 1, 1998. The SWG believed these 

Recommendations, each based on 8 to 12 fatality cases, when appropriately used in switching 

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

Appendix C. Subsequently, the SWG developed condensed versions of each recommendation 

that may involve a series of steps. These shortened versions came to be known as

 1 Following the 1999 SOFA Report (76 older cases) the FRA improved the detail and consistency of their 

investigation process.
3

The Five Lifesavers:

• Secure equipment before action is taken.

• Protect employees against moving equipment.

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

• Communicate before action is taken.

• Mentor less-experienced employees to perform service safely.

1.2.4 Additional Recommendations, October 1999 SOFA Report

In addition to making Five Operating Recommendations in its 1999 SOFA Report, the SWG 

made additional recommendations concerning: 

• Unexpected train movement

• Crew resource management concepts

• 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

For the most part, ‘Additional Recommendations’ do not involve switching operations directly 

(unexpected train movement being the exception). However, the SWG believed these 

recommendations would help reduce risk in switching operations and facilitate the collection of 

fatality information. 

1.2.5 August 2004 SOFA Update

This update increased the total number of cases reviewed from 76 to 124. Further, it divided the 

cases into two groups. The first group contained 64 cases that applied to the Five Operating 

Recommendations. The second group, Special Switching Hazards (SSH), contained 60 cases to 

which no Operating Recommendation applied. The SWG classified the SSH cases into eleven 

categories:

• Close Clearance

• Struck by Mainline Trains

• Employee Tripping, Slipping, Falling

• Free Rolling Railcars

• Unsecured Cars

• Equipment

• Struck by Motor Vehicle or Loading Device
4

• Unexpected Movement of Railcars

• Environment

• Drugs and Alcohol

• Miscellaneous

Chapter 4 of the August 2004 Update, entitled SWITCHING FATALITIES – UNDERSTANDING 

AND PREVENTION, provided new material in four areas:

• Close Clearance

• Struck by Mainline Train

• Job Briefing and Mentoring – Operating Recommendations 3 and 5

• Shoving as a Special Switching Hazard.

1.2.6 Close Clearance

The update urged safety committees, engineering departments, and other railroad industry 

stakeholders to address the following aspects of close clearances.

• Where feasible, re-engineer and/or eliminate close clearances

• Provide safe clearance in future engineering projects

• Mark all permanent close clearance areas with highly visible signs.

• Expand job briefings (Operating Recommendation 3) to include:

o Emphasis of dangers of equipment left fouling

o Warnings to other crews when placing oversized cars on tracks adjacent to their 

work, and

o Discussion of risks of passing trains when working near mainline

1.2.6.1 Struck by Mainline Train

The update discussed the cases, but noted, “Other than general vigilance, awareness, and 

alertness to the switching environment, it is difficult to prescribe a preventive measure.”
5

1.2.6.2 Job Briefing and Mentoring

At the time, the SWG expressed concern about further identifying relevant recommendations.

The update included more guidance by providing example job briefing instructions from various 

carriers. Additionally, the update encouraged:

• Training in effective job briefings

• Active communication to encourage mutual understanding

• Safely stopping job activity if work changes occur or a safety concern arises

• Resuming job activity only after a solution is reached and communicated

• Observing the principles of Train Crew Resource Management2

1.2.6.3 Shoving as a Special Switching Hazard

(CRM).

The SWG noted 116 of the 124 fatalities occurred when equipment was moving; 53% involved 

shoving moves. The update included the following idea, “Wherever feasible, efforts should be 

made to avoid shove movements especially where light engines are involved. Greater use of 

procedures such as running around cars and changing ends should be utilized.”

 2 Appendix I provides material on Train Crew Resource Management.
6

2 SOFA PROCESS

2.1 Introduction

The current SOFA Working Group (SWG) process followed six essential steps:

1. Case Selection

2. Case Review

3. Classification of Cases

4. Analysis – Searching for Commonalities

5. Identification of Preliminary Findings

6. Development of Findings

2.2 Case Selection

The FRA investigates all on-duty employee fatalities as required by 49 U.S.C. Section 20903. 

The SWG identified and selected the case file for each fatality that met the SOFA selection 

criteria. The selection criteria for the new cases in this report are:

All fatalities from 2004 through 2009 involving Train, Yard, and Engine (TY&E) employees 

who were:

• Fatally injured while on the ground.

• Fatally injured while riding on the outside of train equipment.

During the SOFA process, each member examined the fatality investigation narrative for the 

selected cases. Supporting documentation was brought to the meetings. 

2.3 Case Review

The SWG followed four principle steps in reviewing a case: 1) presentation, 2) recording the 

facts, 3) discussion, and 4) agreement on possible factors.

2.3.1 Presentation

The SWG members studied all fatality investigation narratives for the meetings. However, for 

each case, one member was assigned to lead the review by examining the entire case file3 and 

presenting the case to the SWG. The presenter completed a data sheet, which corresponded to the 

SOFA database

4

 3 A case file may contain witness statements, report of interviews, autopsy and/or medical examiner reports, federal 

toxicological testing, locomotive event recorder data, incident photographs and diagrams, “cell” phone information, 

and other documentation substantiating the case narrative.

fields, consistently documenting case facts. The presenter diagrammed the site 

of the fatality to show the location of tracks, relevant equipment, employees, and other pertinent 

elements. After briefly summarizing the case for the SWG, the presenter highlighted relevant 

supporting documentation not found in the summary narrative and responded to questions.

4 The SOFA database is discussed below in Section 2.8.
7

2.3.2 Recording the Facts

Using the data sheet prepared by the presenter, the quantitative and narrative case information 

were entered into the SOFA database during each case presentation. The data included:

• Overview information, such as date, time of incident, location, along with a narrative.

• Background information, such as weather, ground, and lighting conditions.

• Information on the fatally injured employee, such as age and experience.

• Information on the age and experience of involved crew members.

• Information on the movement of equipment and the position and actions of involved 

employees.

Section 2.8 provides more background on the SOFA database and a list of all data elements used 

in the SOFA database is provided in Appendix D.

2.3.3 Case Discussions

After each case presentation, SWG members discussed facts regarding operating characteristics, 

conditions, and events that contributed to the group understanding the circumstances of the 

fatality. Based on personal experience and professional expertise, group members suggested and 

considered theories and alternative explanations. Through extensive discussion, group members 

became very familiar with case details. The ultimate goal of the discussion was to agree on 

factors contributing to the fatality.

2.3.4 Agreement on Possible Factors

The SWG conducted intense discussions of each case until there was an agreement on possible 

factors. The SWG used an approach to define possible factors based on consideration of a

complex combination of operating characteristics, conditions, and events. The SWG did not 

attempt to rank these factors. Instead, it characterized these factors through the use of one or 

more as Possible Contributing Factors (PCFs).

The SWG used the FRA Guide for Preparing Accident/Incident Reports5

In some cases, there were circumstances that did not rise to the level of a PCF. In these cases, the 

circumstance was noted as an “External Factor”. Additional information not captured by a PCF 

or an External Factor was described in the “Other Remarks” section of the database.

and its own defined 

codes as the basis for the PCFs. To each case, the SWG assigned as many PCFs as deemed 

applicable. However, the number of PCFs applied to a case did not exceed a number necessary to 

capture the essence of the circumstances of the fatality. Appendix E provides a list of the PCFs 

used by the SWG.

2.4 Classification of the Cases

After review of all cases, the SWG classified the cases. For this report, the SWG took a different 

approach than previously used in the October 1999 SOFA Report and the August 2004 SOFA 

Update.

 5 Appendix C of FRA Guide for Preparing Accident/Incident Reports (May 1, 2003 edition).
8

2.4.1 October 1999 SOFA Report

The SWG looked at 76 SOFA fatalities from January 1992-June 1998 and classified them into 

five different categories corresponding to the Five Operating Recommendations. For this report, 

we call these SOFA 1-5 cases. For many fatalities, a case qualified for more than one category. If 

a fatality did not meet the criteria for one of these categories, it remained unclassified.

2.4.2 August 2004 SOFA Update

The SWG looked at 48 SOFA fatalities from July 

1998 through December 2003 and again classified 

them into five different categories corresponding to 

the Five Operating Recommendations. As with the 

October 1999 SOFA Report, many fatalities 

qualified for more than one category. 52% of the 

cases reviewed since 1992 fit into one or more of the 

five SOFA categories.

However, the August 2004 Update took SOFA case 

classification a step further. The SWG wanted a way 

to characterize the cases which did not meet the 

criteria for the SOFA 1-5 cases; this amounted to 60 

of the 124 cases reviewed (48%). These cases were 

classified into 11 categories called Special 

Switching Hazards (SSH). Figure 2-1 illustrates the 

idea that the two groups, the SOFA 1-5 cases and the 

SSH cases, were mutually exclusive.

Figure 2-1 August 2004 Update

SOFA 1-5

Cases 

(52%)

SSH

Cases 

(48%)

August 2004 Update

1992 – 2003

SOFA and SSH Mutually Exclusive

The SWG used Special Switching 

Hazard (SSH) as a label for cases that 

were not categorized under the five 

SOFA recommendations.

SOFA 1-5

Cases 

(52%)

SSH

Cases 

(48%)

August 2004 Update

1992 – 2003

SOFA and SSH Mutually Exclusive

The SWG used Special Switching 

Hazard (SSH) as a label for cases that 

were not categorized under the five 

SOFA recommendations.
9

2.4.3 December 2010 Update

For this update, the SWG determined fatalities 

which qualified for one or more of the SOFA 1-5 

categories could qualify also as an SSH. To be 

consistent, the SWG retroactively assigned this 

classification criteria to the 124 cases covered in the 

previous SOFA reports. This resulted in the 179 

cases being classified as SOFA 1-5, SSH, or both.

Figure 2-2 shows the two groups (the five SOFA 

categories and the SSH) are no longer mutually 

exclusive and can overlap. In particular, it shows the 

number of cases categorized as an SSH grows 

because SOFA 1-5 cases can qualify as SSH.

The SWG made this decision because some of the 

SSH have emerged as large and growing fatality 

categories. As an example, Close Clearance is now 

the second largest SOFA fatality category. This new

classification method provided a clear and complete 

case count for these SSH.

The SWG also expanded the number of SSH to 15 and gave each a shorthand code. These are 

shown in Table 2-1.

Table 2-1: The 15 SSH Classifications Used By the SWG

SSHCC: Close Clearance. SSHFR: Free-Rolling Railcars.

SSHDR: Derailment. SSHIH: Industrial Hazard.

SSHDA: Drugs and Alcohol. SSHMC: Miscellaneous.

SSHED: Electronic Device (Cell phone, MP3 

player) SSHST: Struck by Mainline Trains.

SSHET: Employee Tripping, Slipping, or Falling SSHMV: Struck or struck by Motor Vehicle.

SSHEV: Environment.

SSHUM: Unexpected Movement of 

Railcars.

SSHEQ: Equipment. SSHUC: Unsecured Cars.

SSHFC: Failure to Confirm Route of Movement.

2.5 Analysis – Searching for Commonalities

After case classification, the process of discovering ‘commonalities’ began. Commonalities, as 

used in this report, are shared characteristics among cases that may lead to a common solution.

The SOFA database with its search and retrieve abilities allows for rapid queries among the 179

cases. SWG members proposed ideas for SOFA database queries that revealed important 

commonalities. The SOFA database also produced tables imported into statistical software for 

further analysis. Commonalities between database elements discovered through this process led 

to findings.

Figure 2-2 December 2010 Update

SOFA 1-5

Cases

SSH

Cases

December 2010 Update

SSH categories applied to all 

cases (SOFA and non-SOFA)

The number of Special Switching 

Hazards grows.

SOFA 1-5

Cases

SSH

Cases

December 2010 Update

SSH categories applied to all 

cases (SOFA and non-SOFA)

The number of Special Switching 

Hazards grows.
10

2.6 Identification of Preliminary Findings

The SWG, based on the consensus of its members, developed preliminary findings. At this point, 

a finding amounted to a simple statement and the supporting analysis. On February 25, 2010, the 

SWG hosted a SOFA Safety Forum (SSF). The SSF included senior leaders in the railroad 

industry to participate in the further development of these findings and to increase awareness of 

the 2010 SOFA Report. Five preliminary findings were discussed at the SSF, and many ideas 

were generated. The SSF is discussed in Chapter 5 of this report.

2.7 Development of Findings

To develop the findings, the SWG discussed the ideas generated from the SSF about a month 

after it took place. The SWG used various ideas from the SSF and contributed its own thoughts

to produce much of the content in Chapter 3. The 2010 SOFA Report reflects SSF attendee 

comments in the following sections: 

• Section 2.9 Assumptions and Limitations (first two paragraphs)

• Section 3.3.4 Discussion For SOFA 3

• Section 3.4.4 Discussion For SOFA 5

• Section 3.5.4 Discussion For Close/No Clearance

• Section 3.6.4 Discussion For Industrial Hazards

• Section 3.7.4 Discussion For Struck by Mainline Train

Each finding in Chapter 3 includes a discussion of issues and remedies, and ends with a 

conclusion or a SOFA Safety Advisory Statement. 

• The finding on SOFA 1, SOFA 2, and SOFA 4 ends with a conclusion. This means the 

report is evaluating the effectiveness of recommendations from previous reports, and 

there are no new recommendations or remedies beyond those provided in the 1999 SOFA 

Report.

• All other findings include a discussion of issues and corresponding remedies. Some of the 

remedies discussed may be deemed prohibitive to fully implement. Therefore the SWG 

offers ideas to mitigate these issues. The SWG urges railroads to evaluate further the 

suitability of remedies for their particular operating environment. A remedy should not be 

taken as a mandate for changing or writing new rules and is not intended to be 

exhaustive.

• Some findings end with a SOFA Safety Advisory Statement. These statements highlight 

remedies that advise an immediate change to a procedure or an action to improve safety.
11

2.8 SOFA Database

To help manage the six steps discussed above, the SWG has improved its data storage and 

retrieval capability. This capability took the form of a database from which facts and conclusions 

are retrieved. In many respects, the SOFA database was a focal point for the SOFA process and 

served several roles:

• Acted as a central place to record the facts and the conclusions for each case.

• Preserved the SWG’s institutional knowledge about each fatality.

• Provided a framework for SWG discussions about cases.

• Allowed the SWG to assure data and conclusions were recorded consistently across 

cases.

• Provided management of a master table of possible factors.

• Allowed quick retrieval and query of information for commonalities and hypothesis 

testing.

• Facilitated the creation of tables, charts, and graphs important to the SOFA process.

With this report, the software used changed from an Excel® spreadsheet to an Access®

database, both Microsoft® products. The software for earlier reports had limitations in terms of

retrieving information quickly during analysis and deliberations. This new capability removed 

these limitations, allowed for greater coding consistency among cases, and improved the SWG’s

ability to discover commonalities. In essence, the storage of case information changed from a 

‘flat’ file to a relational database, thus providing all the advantages (particularly rapid search 

capability) of this latter data-storage approach.

The database also improved the ability of the SWG to enhance data integrity. Throughout the 

study, the SWG looked for inconsistencies in past data and made corrections when needed. This 

effort to improve data quality will continue.

2.9 Assumptions and Limitations

The SWG used FRA fatality investigation case files, which provided the data used in their 

process. The SWG operates under the assumption that the investigations and associated case 

folders provide a reasonably complete and accurate account of events. The SWG purpose is to 

review cases not to reinvestigate cases. In many cases, years have passed since a fatality has 

occurred. Given this, the SWG does not visit the sites of those fatalities, nor does it typically

contact railroad officials or others about these cases. However on occasion, a SWG member may 

be familiar with a case or have a point of contact that can provide additional insight. In these 

instances, the SWG avails itself of this information.

The SWG focuses its attention on investigation case files because they provide a wealth of detail 

from which SWG draws conclusions. Injury reports do not provide the detail needed to 

consistently evaluate and classify the cases. Basically, injury reports provide information on 

what happened, but not the circumstances leading up to what happened. For example, it is 

difficult to look at an injury report and conclude whether an inadequate job briefing played a role 

in the injury. Despite the limitations in terms of investigative detail, injury reports are still quite 

useful. They supply a good statistical overview on progress regarding safety in switching 
12

operations. The SWG has used some of this information and provides an analysis of severe 

injuries in this report.

The findings in this report are limited to fatalities of TY&E employees who were fatally injured

while on the ground or while riding on the outside of train equipment. They are based on a set of 

variables that are prevalent in switching operations. It is inappropriate to apply these results 

directly to other aspects of the railroad industry without further study. However, other studies 

may find the ideas and methods in this report are worthy of further investigation. The SWG 

hopes the report provides insights for future studies of railroad safety in other areas.
13

3 SWITCHING FATALITIES – UNDERSTANDING AND PREVENTION

3.1 Overview

The SOFA Working Group (SWG) has reviewed 179 switching fatality cases from 1992 through 

2009, an 18-year period. Figure 3-1 shows a year-by-year graph of those fatalities. There is a line 

in the middle of Figure 3-1 which divides the graph into two nine-year periods: the period from 

1992 through 2000 and the period from 2001 through 2009.

Figure 3-1: SOFA Fatalities by Year

The SWG issued its first SOFA report in October 1999, too late to influence the number of 

fatalities for 1999. During 2000, the SWG raised SOFA awareness through presentations at 

railroad industry meetings and forums. Also during 2000, the railroad industry educated its 

workforce about SOFA and the Five Lifesavers. SOFA efforts had little opportunity to have an 

effect during this roll-out period in 2000. This means 2001 was the first year that SOFA could 

have had full effect on reducing fatalities. One way to interpret Figure 3-1 is to regard the first 

nine-year period (1992 – 2000) as the Pre-SOFA period and the second nine-year period (2001 –

2009) as the Post-SOFA period.

The average number of cases in the Pre-SOFA period is 11.1. During the next 9 years, the PostSOFA period, the average number of cases dropped to 8.8, about a 21% reduction. Therefore, the 

railroad industry achieved some success in reducing SOFA fatalities since the first efforts to raise 

SOFA awareness.
14

Figure 3-2 is a paired bar chart which provides a picture of where progress has been made in 

reducing SOFA fatalities and where more attention is needed. The first set of paired bars 

represents fatalities collectively for SOFA 1, 2, and 4. The reduction from 42 fatalities in the 

pre-SOFA period to 12 in the Post-SOFA period is a substantial 71% reduction. This substantial 

reduction runs across the board for SOFA 1, 2, and 4. This report will discuss SOFA 1, 2, and 4 

in more detail below.

Figure 3-2: SOFA Fatalities in Six Areas

The other five sets of paired bars in Figure 3-2 show areas where improvement can be made by 

the railroad industry. The paired bars for both SOFA 3 and SOFA 5 show little or no progress

and a discussion of those fatalities follows below. There are three SSH that are growing issues.

• Special Switching Hazard Close Clearances (SSH-CC) with 11 fatalities in the Pre-SOFA 

period versus 18 fatalities in the Post-SOFA period.

• Special Switching Hazard Industrial Hazard (SSH-IH) with 10 fatalities in the Pre-SOFA 

period versus 16 fatalities in the Post-SOFA period.

• Special Switching Hazard Struck by Mainline Train (SSH-ST) has almost doubled with 7 

fatalities in the Pre-SOFA period versus 13 fatalities in the Post-SOFA period.

SOFA Fatalities For 5 SOFA Recommendations and 3 Major 

Switching Hazards

0

5

10

15

20

25

30

35

40

45

SSH-CC = Close Clearance; SSH-IH: Industrial Hazard; SSH-ST = Struck by Mainline Train

Fatalities

Pre-SOFA (92-00) 42 11 17 11 10 7

Post-SOFA (01 - 09) 12 12 15 18 16 13

SOFA 1, 2, & 4 SOFA 3 SOFA 5 SSH-CC SSH-IH SSH-ST
15

Table 3-1 shows the six largest SOFA categories. This chapter provides findings on these six 

SOFA categories. Although SOFA 2, ranking thirteenth, is no longer one of the top 6 SOFA 

categories, it also is covered in this chapter. Chapter 4 provides more details on all 20 SOFA 

categories.

Table 3-1: SOFA Categories with the Most Fatalities

SOFA 

Classification Description

Pre-SOFA 

(1992-2000)

Post-SOFA 

(2001-2009) Total

SOFA5 – SA1

FE had 1.5 years of experience or less or had inadequate 

training. 17 15 32

SSHCC – SA2 Special Switching Hazard: Close Clearance. 11 18 29

SSHIH – SA3 Special Switching Hazard: Industrial Hazard. 10 16 26

SOFA3 – SA4 Lack of or inadequate job safety briefing. 11 12 23

SOFA1 Adjusting knuckles, adjusting drawbars, or installing EOT 15 6 21

SOFA4

Mixing hand and radio signals or specific distances were not 

given. 17 3 20

SSHST – SA5 Special Switching Hazard: Struck by Mainline Train. 7 13 20

3.2 Substantial Progression SOFA 1, 2, and 4

3.2.1 Finding

There has been substantial progress on reducing fatalities related to SOFA 1, 2, and 4 since the 

SOFA Operating Recommendations were released in the October 1999 SOFA report.

Figure 3-3 shows a paired bar chart displaying the number of SOFA 1, 2, and 4 fatalities over 

two nine-year periods (Pre-SOFA versus Post-SOFA).

Figure 3-3: Fatalities for SOFA 1, SOFA 2, and SOFA 4

The paired bars for each case show an impressive reduction for SOFA 1, 2, and 4. SOFA 1 

fatalities are down 60% from 15 fatalities in the Pre-SOFA period to the 6 fatalities in the PostSOFA period. SOFA 2 fatalities have declined 70% from 10 in the Pre-SOFA period to 3 in the 

Post SOFA period. There has not been a SOFA 2 fatality since 2004. The biggest improvement is 

in SOFA 4 where there has been a decline of over 80% from 17 fatalities in the Pre-SOFA period 

to 3 in the Post-SOFA period.

Fatalities For SOFA 1, SOFA 2, And SOFA 4

0

2

4

6

8

10

12

14

16

18

Pre-SOFA (1992 - 2000) 15 10 17

Post-SOFA (2001 - 2009) 6 3 3

SOFA1 SOFA2 SOFA4
16

3.2.1.1 Background

3.2.1.2 SOFA 1

The October 1999 SOFA report recognized SOFA 1 fatalities as those where the FE6

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.

was 

adjusting knuckles, adjusting drawbars, or installing an end-of-train device. To address these 

fatalities, the SWG developed Operating Recommendation 1:

This recommendation has since been summarized as one of The Five Lifesavers:

Secure equipment before action is taken.

3.2.1.3 SOFA 2

The October 1999 SOFA report classified SOFA 2 fatalities as those where an FE was struck by 

equipment other than their own7

When two or more train crews are simultaneously performing work in the same yard or 

industry tracks, extra precautions must be taken:

. The report addressed this problem with Operating 

Recommendation 2:

• 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.

This recommendation has since been summarized as one of The Five Lifesavers:

Protect employees against moving equipment.

 6 In the October 1999 SOFA Report, FE meant “fatality of an employee.” 7 SOFA 2 refers to strikes on yard or industry tracks. It does not include FEs who were struck by trains on main 

track.
17

3.2.1.4 SOFA 4

The October 1999 SOFA report recognized SOFA 4 fatalities as those where there was a 

combination of hand and radio signals and/or specific distances were not given during ongoing 

movement of equipment. To address these fatalities, the SWG created Operating 

Recommendation 4:

When using radio communication, locomotive engineers must not begin any shove move 

without a specified distance from the person controlling the move. Strict compliance with 

“distance to go” communication must be maintained. 

When controlling train or engine movements, all crew members must communicate by 

hand signals or radio signals. A combination of hand and radio signals is prohibited. All 

crew members must confirm when the mode of communication changes.

This recommendation has since been summarized as one of The Five Lifesavers:

Communicate before action is taken.

The August 2004 SOFA Update included updated statistics on SOFA 1, 2, and 4, but did not 

provide additional guidance. The case numbers for the fatalities involving SOFA 1, 2, and 4 are 

shown in the Table 3-1 below. Appendix A of this report provides the narratives for these cases.

Table 3-2: Case Numbers for SOFA 1, 2, and 4

SOFA1 SOFA2 SOFA4

FE-1992-18 FE-1992-30 FE-1992-03

FE-1994-26 FE-1993-31 FE-1992-08

FE-1994-32 FE-1994-06 FE-1992-14

FE-1995-11 FE-1994-31 FE-1992-22

FE-1995-12 FE-1995-11 FE-1993-26

FE-1995-29 FE-1995-18 FE-1993-30

FE-1996-09 FE-1997-05 FE-1994-29

FE-1996-24 FE-1998-05 FE-1994-31

FE-1997-25 FE-1998-16 FE-1995-09

FE-1998-15 FE-2000-25 FE-1997-04

FE-1998-17 FE-2002-19 FE-1997-16

FE-1999-16 FE-2003-03 FE-1997-45

FE-1999-24 FE-2004-23 FE-1998-37

FE-2000-09 FE-1999-01

FE-2000-21 FE-1999-16

FE-2001-08 FE-2000-22

FE-2002-12 FE-2000-29

FE-2002-16 FE-2002-17

FE-2003-20 FE-2007-18

FE-2004-22 FE-2008-19

FE-2009-14
18

3.2.2 Discussion

Operating Recommendations 1, 2, and 4 had a structure that highlighted procedural safety rules

where compliance with the rules could be monitored. For example, SOFA 1 led to increased 

compliance with a rule-oriented procedure where employees had to request three-step protection 

before moving between cars and could not move until hearing “set and centered” as a response.

Furthermore, it was possible to monitor compliance with the procedure and take corrective action 

when the procedure was not followed.

3.2.3 Conclusion

The railroad industry achieved a reduction in fatalities in SOFA incident category 1, 2, and 4 by 

focusing attention on the tasks associated with operating recommendations presented in the 1999 

SOFA Report, since known as The Five Lifesavers. Pre-existing rules, in place at the time of the 

1999 SOFA Report, enabled the railroad industry to monitor the tasks associated with these 

operating recommendations.

3.3 No Substantial Progress on SOFA 3 (Lack of or inadequate job briefing)

3.3.1 Finding

There has been no substantial progress on reducing fatalities related to SOFA 3 incidents since 

the SOFA Operating Recommendations were released in the 1999 SOFA report. SOFA 3 is the 

fourth largest category of SOFA fatalities. Figure 3-4 illustrates SOFA 3 fatalities over two nineyear periods (Pre-SOFA versus Post-SOFA) and an increase from 11 to 12 fatalities between the 

two periods. Appendix G provides a more detailed comparison between the Pre-SOFA and PostSOFA periods for SOFA 3.

Figure 3-4: SOFA 3 Fatalities Over Two Nine-Year Periods

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)
19

3.3.2 Background

The 1999 SOFA Report classified SOFA 3 fatalities as those involving a lack of or inadequate 

job briefing. The report addressed this problem with Operating 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.

This recommendation has since been summarized as one of The Five Lifesavers: 

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

The August 2004 SOFA Update included more guidance on job briefings by providing example 

job briefing instructions from various carriers. Additionally, the update encouraged the 

following:

• Training in the art of job briefings

• Active communication to encourage mutual understanding

• Safely stopping job activity if work changes occur or a safety concern arises

• Resuming job activity only after a solution is reached and communicated

• Observing the principles of Train Crew Resource Management8

The case numbers for the fatalities involving SOFA 3 are shown in the Table 3-3 below. Pages 7 

- 12 in Appendix A of this report provide the narratives for these cases.

(CRM).

3.3.3 Statistical Background

Unlike fatalities for many SOFA categories, fatalities involving SOFA 3 are not concentrated in 

any one area. These fatalities occur on all types of track and for all movement types9

. They occur 

when the FE is riding or on the ground. They occur for experienced and inexperienced 

employees. In short, a statistical analysis does not allow us to find a remedy by focusing only on 

a few situations.

 8 Appendix I provides materials on Train Crew Resource Management.

9 Push movements, shove movements, and free rolling cars.
20

Table 3-3: Twenty-Three Cases of SOFA 3

Case Number Incident Date Railroad City State Job Description Age

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FE-2007-19 30-Aug-07 BNSF Stockton CA RCL Operator 50

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

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

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

3.3.4 Discussion

In a previous SOFA report, the SOFA working group used the term “job” and the phrase “work 

changes.” Since there has been no substantial progress on reducing SOFA 3 fatalities since the 

1999 SOFA report, the SWG decided it would be helpful to define job and work changes. The 

SWG defines job as a set of interrelated and interdependent tasks. The phrase “work changes” is 

defined as a deviation or alteration of any task. Each crew member should consider the following 

five questions for each task or when the work changes from a previous job briefing:

• Who – Identify the person who will act 

• What – Identify what act is about to be done 

• Where – Identify where the action will occur

• When – Identify when the action occurs

• Why – Identify why the act is being done.

We believe these five questions are the foundation of an initial job briefing, and for subsequent

job briefings, when applied to each task comprising the larger job at hand. Further, these five 

questions can be applied to any task, and a successful job briefing can be maintained. Some 

railroads successful in preventing fatalities related to job briefings attribute this to a continuous

updating of the job status among all crew members.
21

In several cases where fatalities occurred, for instance in Struck by Mainline Trains, one or more 

of the five questions were known to each member of the affected crew. However, one or more of 

the questions, such as “When”, were not discussed or answered before action was initiated, 

resulting in a fatality.

The issues with job briefings were discussed thoroughly at the SOFA Safety Forum (SSF) and 

during SWG meetings. The following are issues and remedies for the railroad industry to 

consider.

3.3.4.1 Issue: Unexpected Change in Circumstances

When an unexpected change in circumstances, such as a failure to couple, occurs, a departure 

from the original job briefing may happen without an updated job briefing. During the postSOFA era, there were seven SOFA 3 fatalities in yards and industrial properties; five of these 

(FE-2002-16, FE-2005-14, FE-2005-33, FE-2007-19, and FE-2008-37) occurred when a change 

or anomaly occurred from the original job briefing. Case FE-2005-33 in Lugoff, SC is an 

instructive example: 

A three person crew shoving into an industry track found cars left foul of an adjacent 

track by industry employees. The conductor held a job briefing with the brakeman on the 

moves to be made, and the brakeman understood he would control the switching and car 

movements. After shoving the cars to make the coupling, the conductor told the brakeman 

the cars were coupled and he was in the clear. The brakeman attempted to uncouple from 

the cars, but failed. He then requested the engineer make a second move to create slack 

between the cars so they could be uncoupled. The engineer complied and the conductor 

who was in the foul of track and equipment suffered fatal injuries.

Remedy: Management and employees must encourage all to remain vigilant for changes in or 

anomalies affecting the job tasks. Remind all crew members of the necessity to stop a job and 

request an update to the original job briefing when circumstances change10

3.3.4.2 Issue: Measuring the Effectiveness of the Application of Operating 

Recommendation 3

.

It is challenging to measure the effectiveness of the application of Operating Recommendation 3 

(i.e., job briefing). Crafting an effective behavioral rule, practice, or procedure that can be 

assessed for compliance is difficult and suggests the railroad industry needs to go beyond the 

“rulebook” approach. The railroad industry and its employees should identify additional methods

to make job briefings more effective.

Remedy: Adopt and/or reinforce training programs, such as Train Crew Resource Management11

 10 See Section 7.2 for the SWG position on empowerment and discipline.

(CRM), that promote improved interpersonal communication, situational awareness, problem 

solving, decision making and teamwork, and provide strategies for appropriately challenging and 

questioning authority when safety could be jeopardized. The railroad industry should 

reemphasize the importance of job briefings and procedures for effective intra-crew 

communication, which has the potential to make a major contribution to switching operations

safety. The railroad industry must continue to develop programs that provide a team-based 

framework for evaluating conditions, applying rules, and performing work tasks safely.

11 Appendix I provides materials on Train Crew Resource Management.
22

3.3.5 Briefings – Job or Safety (SOFA 3) – SOFA Safety Advisory Statement 2010

The SWG believes ongoing communication is crucial among employees during the entire time 

switching operations are being performed, including periods when tasks are changing or when 

anomalies occur. A job briefing is a two-way exchange of information to reach an understanding 

of the tasks being performed.

Despite considerable efforts within the railroad industry, more than half of SOFA 3 fatalities in 

yards and industrial properties occurred when a job task changed and an update to the job 

briefing did not occur. The SWG believes more progress can be made in the area of work 

changes. When work changes occur, the employees involved may not maintain currency with 

these changes; thus, they may be unaware of the tasks to be performed, and this may place 

them in peril. The railroad industry must remain vigilant regarding fatalities, and when work 

changes occur, employees must regroup, take appropriate steps to provide protection, and not 

proceed until an update to the job briefing is done12

3.4 Little Progress on SOFA 5 (Employees with 1.5 Years of Experience)

.

3.4.1 Finding

There has been little progress on reducing fatalities for SOFA 5 incidents since the SOFA 

Operating Recommendations were released in the first SOFA report in October 1999. With 32 

cases, SOFA 5 is the largest category of SOFA fatalities. Figure 3-5 shows a bar chart displaying 

the number of SOFA 5 fatalities over two nine-year periods (Pre-SOFA versus Post SOFA). It 

shows little progress has been made on reducing SOFA 5 fatalities between the two nine-year 

periods.

Figure 3-5: SOFA 5 Fatalities Over Two Nine-Year Periods

 12 See Section 7.2 for the SWG position on empowerment and discipline.

SOFA 5 Fatalities Over Two Nine-Year Periods

0

2

4

6

8

10

12

14

16

18

Fatalities

SOFA 5 17 15

Pre-SOFA (1992 - 2000) Post-SOFA (2001 - 2009)
23

3.4.2 Background

While working on the first SOFA report in October 1999, the SWG was concerned with the 

number of inexperienced employees13

The 1999 report addressed the issue of inexperienced employees by creating Operating 

Recommendation 5:

who were fatally injured during switching operations and 

developed Operating Recommendation 5. Since the 2004 report, the SWG has used 1.5 years as 

the criteria for identifying SOFA 5 cases.

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. 

This recommendation has since been summarized as one of The Five Lifesavers:

Mentor less-experienced employees to perform service safely.

The SOFA update of August 2004 urged the railroad industry to include the principles of CRM14

The cases fatalities involving SOFA 5 are shown in the Table 3-4 below. Pages 16 – 22 in 

Appendix A of this report provide the narratives for these cases.

in their training programs to help reduce fatalities to inexperienced employees.

 13 The criteria used in the October 1999 report for identifying SOFA 5 cases were fatalities involving employees 

with 1 year or less craft experience. However, another FE with 1.5 years of craft experience was included in the 

SOFA 5 cases because he had a record of interrupted service, and hence, was still an inexperienced employee in the 

judgment of the SWG. SWG believes that an employee who has a limited familiarity of the physical work 

environment or has not been at a location for an extended period may be an “inexperienced employee”.

14 Appendix I provides materials on Train Crew Resource Management.
24

Table 3-4: 32 SOFA 5 Cases

Case 

Number

Incident 

Date Railroad City State Job Description Age

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FE-2004-20 02-Sep-04 BNSF Clovis NM RCL Operator 26

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

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

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

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

FE-2005-23 05-Jul-05 BNSF Emporia KS Yard Helper 27

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

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

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

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

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

FE-2008-37 15-Nov-08 MRL Laurel MT Yard Brakeman 39
25

3.4.3 Statistical Background

Table 3-5 shows fourteen SOFA 5 cases involved shove moves. Seven of these (50%) involved a 

failure to control the shove. This percentage is more than twice that of non-SOFA 5 cases 

involving shove moves (20%)15

Table 3-5: SOFA 5 Cases Involving a Shove Move – All Railroads Failure to Control the Shove

. 

SOFA 5 Cases Non-SOFA 5 Cases

Cases with failure to control shove (24) 7 17

Total cases involving shoves (100) 14 86

Percentage for failure to control shove 50% 20%

There is another notable statistic to keep in mind. Table 3-6 shows SOFA cases where there was 

a surviving crew member who also had 1.5 years of experience or less. The table shows 14 of the 

32 SOFA 5 cases (44%) involved an inexperienced surviving crew member. The data suggests 

that a train crew with multiple inexperienced crew members faces an increased risk of a fatality.

Table 3-6 Surviving Inexperienced Crew Member

SOFA 5 Cases Non-SOFA 5 Cases

Cases with surviving inexperienced employee on 

the FE's crew (31) 14 17

Total cases (179) 32 147

Percentage for surviving inexperienced employee 44% 12%

Table 3-7 shows 12 of the 32 SOFA 5 cases (38%) involved a regional or short line railroad. 

This is more than twice the percentage of non-SOFA 5 cases (18%). Table 3-8 shows 20 of the 

120 SOFA 5 cases (62%) involved a Class I railroad.

Table 3-7: SOFA 5 Cases - Regional and Short Line Railroads

SOFA 5 Cases Non-SOFA 5 Cases

Cases with regional/short line RRs (39) 12 27

Total cases (179) 32 147

Percentage for regional/short line RRs 37.5% 18.5%

Table 3-8: SOFA 5 Cases – Class I Railroads

SOFA 5 Cases Non-SOFA 5 Cases

Cases Class I RRs (140) 20 120

Total cases (179) 32 147

Percentage for Class I RRs 62.5% 81.5%

 15 Out of the 179 SOFA cases, 100 cases involved shove moves.
26

3.4.3.1 Discussion

The issues with inexperienced employees were discussed thoroughly at the SOFA Safety Forum 

(SSF) and during SWG meetings. The following are issues and remedies for the railroad industry

to consider.

3.4.3.2 Issue: Possible Imbalance Between Classroom Training and OJT

There may not be an effective balance of classroom training and On-The-Job-Training (OJT) 

within the railroad industry. Although necessary, classroom rules training alone is not enough.

OJT training may need to be reviewed to allow those with less than 1.5 years of experience more 

time to gain familiarity with the demands of the job. As an example, inexperienced employees 

shown in Table 3-3 above were fatally injured when they failed to control a shove movement. 

Remedy: Review OJT programs. A well designed OJT program should make sure the 

inexperienced employee receives adequate training. Following the period of OJT, identify the 

areas of inadequacies of the inexperienced employee’s skills to provide targeted training that will 

allow the employee to meet the demands of the job. Smaller railroads in particular may benefit 

from a review of their OJT and improved follow-up with inexperienced employees.

3.4.3.3 Issue: Finding Enough Experienced Employees to Mentor New Employees

Mentoring was a method suggested in the 1999 SOFA report to acclimate the new hire employee 

to the railroad environment and its dangers. As the rate of attrition grows and the number of new 

hires increases, it can be a challenge to find those who can or will work with the new hire 

employee as a mentor. Changes in crew size, sometimes through introduction of new 

technologies, have made mentoring more challenging.

Inexperienced employees may face the possibility of a different mentor each day or, find 

themselves without a “mentor” who is willing or capable. Even if good mentors can be found, 

inexperienced employees may believe they already know correct procedures, tuning out their 

mentors at critical moments.

Remedy: Set criteria for good mentors, recruit them, and ensure inexperienced employees have a 

good mentor on the crew. Emphasize personal accountability to the new hire. The inexperienced

employee should respect the mentoring process that equates to good listening and a willingness 

to apply the safe practices that are taught.

3.4.3.4 Issue: Risk of Fatality Increased When Crews Have More Than One 

Inexperienced Employee

The risk of a fatality occurring is compounded when there is more than one inexperienced 

employee on the crew (See Table 3-4). The inexperienced employee may face difficulties in 

performing at an effective level because of the relative short period of time spent in the craft or 

because of the amount of time spent in training. Having multiple inexperienced employees on the 

same crew possibly creates an excessive burden on each crew member. 

Remedy: Avoid making up crews with more than one inexperienced employee. When 

inexperienced employees are working, an effort should be made not to place multiple employees 

with less than 1.5 years of experience on the same crew. If this is not possible, local management 

should be notified immediately of the crew make up.
27

3.4.3.5 Issue: Productivity Expectations From Management and Crew May Not Change

Productivity expectations from management and crew may not change when an inexperienced 

crew member is present. An inexperienced employee may feel pressured to proceed with a task 

even when he or she is uncertain about the situation.

Remedy: The railroad industry has an obligation to ensure inexperienced employees understand 

their safety is far more important than productivity. Accordingly, the railroad industry needs to 

adjust productivity expectations while inexperienced employees gain competency.

3.4.3.6 Issue: Measuring the Effectiveness of the Application of Operating 

Recommendation 5

It is challenging to measure the effectiveness of the application of Operating Recommendation 5 

(i.e., Inexperienced Employee). Crafting an effective behavioral rule, practice, or procedure that 

can be assessed for compliance is difficult and suggests the railroad industry needs to go beyond 

the traditional, “rulebook” approach.

Remedy: The railroad industry should identify additional methods to make education, training, 

and mentoring of inexperienced employees more effective, including a method to provide 

feedback on what approaches and techniques work well.

3.4.4 Inexperienced Employee (SOFA 5) – SOFA Safety Advisory Statement 2010

Since the 1999 Report, the SWG emphasis on mentoring has not achieved a substantial 

reduction in SOFA 5 fatalities. It is critical for the railroad industry to provide the 

inexperienced employee adequate OJT. Without abandoning the commitment to 

mentoring, the railroad industry should improve OJT to include targeted training for the 

inexperienced employee. Providing follow-up review of skills, and targeted training by 

the railroad industry enables an inexperienced employee to meet the demands of the 

job. Smaller railroads in particular may benefit from a review of their OJT, and improved

follow-up with inexperienced employees.

3.5 Close/No Clearance – A Growing Issue

3.5.1 Finding

Fatalities due to close or no clearances are a growing issue.

Figure 3-6: SSH Close/No Clearance Fatalities Over Two Nine-Year Periods

Special Switching Hazard Close/No Clearance Fatalities Over Two Nine-Year 

Periods

0

2

4

6

8

10

12

14

16

18

20

Fatalities

SSHCC 11 18

Pre-SOFA (1992 - 2000) Post-SOFA (2001 - 2009)
28

Close/No clearance is the second largest category of SOFA fatalities. Figure 3-6 displays the 

number of close/no clearance fatalities over two nine-year periods, pre-SOFA versus post-SOFA.

It shows fatalities due to close/no clearances are a growing issue and could imply the guidance 

provided in the August 2004 SOFA Update (See Section 3.5.2 immediately below) has had little 

or no effect.

16

3.5.2 Background

In the August 2004 SOFA Update, the SWG addressed close clearances in a chapter entitled 

SWITCHING FATALITIES – UNDERSTANDING AND PREVENTION. This chapter provided 

the SWG’s definition of close clearance and urged safety committees, engineering departments, 

and other railroad industry stakeholders to address all aspects of close clearances including: 

• Re-engineer and/or eliminate close clearances, where feasible

• Provide safe clearance in future engineering projects

• Mark all permanent close clearance areas with highly visible signs

• Expand job briefings (Operating Recommendation 3) to include:

o Emphasis of dangers of equipment left fouling

o Warnings to other crews when placing oversized cars on tracks adjacent to their 

work 

o Discussions of risks of passing trains when working near mainline

The cases for fatalities involving close/no clearance are shown in the Table 3-7 on the next page.

Pages 22-28 in Appendix A of this report provide the narratives for these cases.

3.5.3 Definitions

Terminology can be problematic when discussing close/no clearance situations. The SWG 

defined the following terms in creating this 2010 report. These definitions arose from the 

analysis of the 179 cases from 1992-2010.

No Clearance: Insufficient space for the employee to avoid being struck if passing or being 

passed by an object, structure, or equipment.

Example - FE-2000-23: A three person local switching crew was in the process of setting cars 

into a track within an industry. The switchman was riding the side ladder of the leading end of 

the leading car as it went into the building. The doorway would not clear a man riding on the 

side of the car and the trainman was fatally injured as he was compressed between it and the car 

he was riding.

Close Clearance: Insufficient space for the employee to take evasive action to avoid being struck 

by moving equipment that derails into an object, structure, or other equipment.

Example - FE-2009-26: A two-person RCL crew shoved five empty cars into a snow-covered 

industry track. Ice build-up on the track caused the lead car of the movement to derail. The RCL 

 16 Some growth is due to the increased number of cases in which the FE also was struck by a mainline train: Zero 

cases in the pre-SOFA years versus four cases in the post-SOFA years. If the four cases in which the FE was struck 

by a mainline train are removed, there is still growth from the pre-SOFA years to the post-SOFA years.
29

operator, riding the lead car and controlling the move, was crushed against the side of an 

industry building and fatally injured.

Permanent Close/No Clearance: A fixed structure that remains in the same location from day to 

day, such as a building, loading dock, fence, post, beam, or other permanent structure, that an 

employee passes.

Example – FE-1996-12: Yard crew, engineer, conductor and switchman, switching at an 

industry. While crew was shoving two cars to a spot inside an industry building, FE (switchman) 

was rolled between lead box car and unloading platform. Platform or building was not marked 

with any type of ‘no-clearance’ or ‘close clearance’ signage.

Temporary Close/No Clearance: A movable object, including equipment on or near one track 

fouling another track, rolling stock on an adjacent track, stacks of cross ties, construction 

materials, and doors or gates left open, that passes by an employee or an employee passes.

Example – FE-2006-26: A three person switching crew working with a student switchman began 

switching following a safety briefing. Two rail cars kicked toward a track stalled foul of the 

clearance point on the adjacent track. The next car switched was rolling free when the footboard 

yardmaster/switch foreman and student switchman saw that the cars were fouling the clearance 

point. The footboard yardmaster/switch foreman in an attempt to board and stop the free rolling 

car became trapped between the sides of the cars and carried for a distance between the cars.

Table 3-10 provides a breakout by type of clearance and track for the 29 cases. It suggests the 

mix of close/no clearance hazards encountered by employees is different on industry track versus 

other track.
30

Table 3-9: 29 Cases Involving Close/No Clearance

Case Number Incident Date Railroad City State Job Description Age

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FE-2009-26 29-Dec-09 BNSF Minneapolis MN RCL Operator 44
31

Table 3-10: Type of Clearance and Track

Permanent Temporary Total

Industry Track 10 4 14

Other Track 4 11 15

Total 14 15 29

3.5.4 Statistical Background

Table 3-11 shows 14 of the 29 close/no clearance fatality cases (48%) occurred on industry track.

This is more than twice the percentage of other, non-Close/No Clearance cases (20%).

Table 3-11: Close/No Clearance Industry Track Cases

Close/No Clearance Cases Non-Close/No Clearance Cases

Cases on industry track (44) 14 30

Total cases (179) 29 150

Percentage for industry track 48% 20%

Table 3-12 shows 7 of the 29 close/no clearance fatality cases (24%) involved derailments. This 

percentage is three times more than other, non-Close/No Clearance cases (7%). All seven 

derailments for close/no clearance cases occurred on industry track.

Table 3-12: Close/No Clearance Derailment Cases

Close/No Clearance Cases Non-Close/No Clearance Cases

Cases with derailments (17) 7 30

Total cases (179) 29 150

Percentage for derailments 24% 7%

3.5.5 Discussion

The issues with close/no clearance were discussed thoroughly at the SSF and during SWG 

meetings. Many permanent close/no clearance structures have existed in the industry before 

standards, of any kind, were established. The following are issues, remedies, and possible 

mitigations for the railroad industry to consider.

3.5.5.1 Issue: Removal of Close/No Clearance Conditions

Removal of close/no clearance conditions in some instances is deemed cost-prohibitive.

Remedy: Eliminate close/no clearance conditions, and provide safe clearance in future 

engineering projects.

Mitigation(s): Improve signage to be standardized and instructional. Inadequate signage issues 

typically can be addressed at a lower cost, including maintenance, than other engineering 

remedies. In addition, increase illumination and/or lighting at night.
32

3.5.5.2 Issue: Employee Unfamiliar with Close/No Clearance Hazards

Sometimes an employee is unfamiliar with the close/no clearance hazards on railroad and/or 

industrial properties.

Remedy: Prepare employees to identify and avoid close/no clearances. Examples include the 

following:

• Provide job aids, such as maps that highlight close/no clearances.

• Discuss the location and potential for close/no clearances in job briefings.

• Assist employees with little or no familiarity with the physical characteristics at that 

location, such as working with a person familiar with that location.

• Encourage employees to inspect the work site before acting.

• Report close/no clearance issues (e.g., no signage, temporary obstruction) through 

established procedures. Responsible parties must follow up on these reports, ensure the 

workforce is notified, and take corrective action.

• Share near-miss and close-call experiences with employees.

3.5.5.3 Issue: Practices for Handling Close/No Clearances are Inconsistent

Practices for handling close/no clearances are inconsistent across the railroad industry or within a 

particular property. An employee can be uncertain of when one should inspect the work site, 

when to walk instead of ride, or which side of the car to ride. Even when standards exist, some 

employees deviate from best practices for years without consequences; deviation from best 

practice can become the norm.

Remedy: Establish standards on how employees should handle close/no clearance situations so 

they know when to walk or when and where to ride. The concepts behind “defensive switching”

come into play here, including the following:

• Look for hazards

• Ride the side away from hazards

• Plan for the worst case scenario, such as a derailment, and prepare an escape strategy

• Maintain focus and avoid distractions, such as holding unnecessary conversations, doing 

paperwork, or using cell phones

3.5.6 Close Clearances – SOFA Safety Advisory Statement 2010

The SWG reemphasizes that removing the hazard is the best way to address close/no 

clearances. Yet, in many cases a railroad or industry will not be able to eliminate the close/no 

clearance condition. At the minimum, the SWG believes that proper signage should be 

implemented and be instructive to the employee. Additionally, the sign should be an 

appropriate17

 17 The use of the term “appropriate” is intended to address the possibility that the sign may be posted too close or too 

far from the hazard. Too much distance may contribute to the employee forgetting the warning.

distance from the close/no clearance location and on the same side. Signage

must: (a) announce the clearance issue and (b) instruct the employee who is controlling the 

movement to dismount and remain dismounted from the equipment while passing the close/no
33

clearance location. One method to determine the signage design, appropriate distance, and 

position may be to organize a management-labor working group.

3.6 Industrial Track Hazard – A Growing Issue

3.6.1 Finding

Industrial Track Hazard is the third largest category of SOFA fatalities. Figure 3-7 shows a bar 

chart displaying the number of fatalities involving industrial track hazards over two nine-year 

periods (Pre-SOFA versus Post SOFA). It shows fatalities involving industrial track hazards are 

a growing issue.

Figure 3-7: Special Switching Hazard Industrial Track Hazard Over Two Nine-Year Periods

3.6.2 Background

Industrial Track Hazard is a new category of SOFA fatality and has not been used in previous 

SOFA reports. Industrial Track Hazards include cases where a structure, vehicle, or temporary 

obstruction on industrial track played a significant role in 26 SOFA fatalities. It can include cases 

where the action of industrial plant employees played a role. 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. For example, a case where the crew failed to follow proper 

radio protocol would be categorized as a SOFA 418 case, not an Industrial Track Hazard case

even though it may occur on industrial track. Using the criteria discussed above, 26 of the 44

fatalities which occurred in industrial track qualified as cases involving an industrial track 

hazard.

 18 SOFA 4 Criteria: Move controlled by a combination of hand and radio signals or specific distances were not 

given.

Special Switching Hazard Industrial Track Hazard 

Over Two Nine-Year Periods

0

4

8

12

16

20

Fatalities

SSHIH 10 16

Pre-SOFA (1992 - 2000) Post-SOFA (2001 - 2009)
34

The cases for the fatalities involving industrial track hazards are shown in the Table 3-13 below.

Pages 47 – 52 in Appendix A of this report provide the narratives for these cases.

Table 3-13: 26 Cases Involving Industrial Track Hazards

Case Number Incident Date Railroad City State Job Description Age

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

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

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

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

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

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

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

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

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

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

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

FE-2005-23 05-Jul-05 BNSF Emporia KS Yard Helper 27

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

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

FE-2006-22 04-Dec-06 UP Carson CA RCL Operator 35

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

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

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

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

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

FE-2009-26 29-Dec-09 BNSF Minneapolis MN RCL Operator 44
35

3.6.3 Statistical Background

Table 3-14 shows 14 of the 26 industrial hazard cases (54%) involved close/no clearance. This 

percentage is far higher than for other types of non-Industrial Track Hazard cases (10%).

Table 3-14: Industrial Track Hazard Close/No Clearance

Industrial Track 

Hazard Cases

Non-Industrial Track Hazard 

Cases

Cases involving close/no clearance (29) 14 15

Total cases (179) 26 153

Percentage for close/no clearance 54% 10%

Table 3-15 shows 7 of the 26 industrial hazard cases (27%) involved derailments. This 

percentage is more than three times the percentage for other, non-Industrial Track Hazard cases 

(7%). All seven derailments involved close/no clearance issues.

Table 3-15: Industrial Track Hazard Derailments

Industrial Track Hazard Cases Non-Industrial Track Hazard Cases

Cases involving derailments (17) 7 10

Total cases (179) 26 153

Percentage for derailments 27% 7%

Table 3-16 shows 6 of the 26 industrial hazard cases (23%) involved motor vehicles. This 

percentage is more than ten times the percentage for other, non-Industrial Track Hazard cases 

(2%).

Table 3-16: Industrial Track Hazard Motor Vehicles (Struck By)

Industrial Track Hazard Cases Non-Industrial Track Hazard Cases

Cases involving motor vehicles (9) 6 3

Total cases (179) 26 153

Proportion for motor vehicles 23% 2%

Appendix G in Volume II provides additional statistics on industrial track hazard cases.

3.6.4 Discussion

The issues with industrial track hazards were discussed thoroughly at the SSF and during SWG 

meetings. The following are issues and remedies for the railroad industry to consider.

3.6.4.1 Issue: Industry Track Agreements May Not Be Current

“Industry Track Agreements”19

 19 The term Industry Track Agreements as used in this report encompasses similar terms within the industry such as 

track agreement, lease/service agreement, side track agreement, etc.

may not be current, require notification of a change in 

conditions, and/or may allow conditions to become unsafe due to changes over time. Review of 

agreements is inconsistent across the railroad industry. Shippers/receivers utilizing the same 

industrial lead may have different industry track agreements.
36

Remedy: Implement consistent content, oversight, and enforcement of industry track agreements.

• Agreements, practices, or policies should include the following provisions:

o Maintenance of track and walkways. This includes ice and snow removal, 

clearing of debris alongside the track, and immediate removal of objects or debris 

blocking the track or walkway. This directly impacts the decision of the groundservice employee to walk or ride equipment.

o Removal of close/no clearance conditions. (See section 3.5.5.1)

o Needs assessment for the installation and maintenance of lighting.

o Marking of private industry road crossings clearly.

o Definition and control of the separation of road and plant vehicle operations from 

rail traffic.

o Definition and control of the separation of non-railroad personnel from railroad 

switching operations.

o Notification to appropriate railroad personnel of a change in conditions.

• Oversee and enforce industry track agreements. 

o Empower employees to stop work when hazards that endanger the crew are 

identified and notify the proper authority immediately20

o Respond to reports of unsafe conditions. A failure to respond leaves the hazard 

uncorrected and degrades confidence in the reporting system.

. Safety concerns must 

override the desire to complete a task.

o Conduct inspections to ensure compliance with industry track agreements. 

Railroad managers and safety committees as appropriate should involve 

themselves and conduct visits to industry property.

o Visit the property to ensure close/no clearance issues have been eliminated or 

mitigated. Check the condition of walkways and track during the visit21

3.6.4.2 Issue: Training in Plant Characteristics May Be Inconsistent

. If new 

problems are identified, alert the customer.

Training in plant characteristics may be inconsistent. An employee who is unfamiliar with an 

industrial property may not be aware of the industrial hazards. Job aids such as maps usually do 

not exist.

Remedy: Prepare employees to identify and avoid industry hazards. Examples include the 

following: 

• Provide job aids, such as maps that highlight industrial hazards.

• Discuss the location and potential for industrial hazards in job briefings.

 20 See Section 7.2 for the SWG position on empowerment and discipline. 21 Table 3-7 shows 27% of Industrial Track Hazard Cases involve a derailment. The majority of these are due to an 

obstruction on the track.
37

• Assist employees with little or no familiarity with the physical characteristics at that 

location, such as working with a person familiar with that location.

• Encourage employees to inspect the work site before acting.

• Share near-miss and close-call experiences with employees.

3.6.4.3 Issue: Collisions with Motor Vehicles While Riding Railroad Equipment

Nine employees died in a collision with a motor vehicle while riding railroad equipment during a 

shove movement over a grade crossing. 

Remedy: An employee must not ride railroad equipment through a grade crossing during a shove 

movement.

• Advise industry to educate and instruct vehicle operators on separation of non-railroad 

personnel from railroad switching operations.

• Needs assessment for the installation and maintenance of lighting

• Marking of public and private industry road crossings clearly.

• Definition and control of the separation of road and plant vehicle operations from rail 

traffic.

3.6.5 Industrial Hazards – SOFA Safety Advisory Statement 2010

Railroads and industries need to have Industry Track Agreements, practices, or policies in 

place, and these should contain oversight and enforcement of the safety provisions. Railroads 

must provide employees with the tools and/or assistance to allow them to safely perform their 

work while within an industry.

Employees need to be empowered to make a decision to stop work when an unsafe condition 

presents itself22

Employees engaged in switching operations must not ride railroad equipment through a grade 

crossing during a shove movement. Industries need to educate and instruct all vehicle operators 

concerning separation between their vehicle and railroad equipment by being attentive to 

movements in the industry. At the minimum, the SWG believes that proper education and 

instruction should be implemented by the industry. Additionally, signage and lighting should be

appropriate for the crossing protection needed. 

. Railroad managers must be educated to encourage employees to make a 

good faith effort to identify and report hazards at industries. Employees making a good faith 

effort to identify and report hazards will not be subject to discipline, discrimination, or 

harassment for doing so.

 22 See Section 7.2 for the SWG position on empowerment and discipline.
38

3.7 Struck by Mainline Trains – A Growing Issue

3.7.1 Finding

Struck by Mainline Trains, with 20 cases, is tied for the sixth largest category of SOFA fatalities.

Figure 3-8 displays the number of struck by mainline train fatalities over two nine-year periods 

(Pre-SOFA versus Post-SOFA). It shows fatalities for TY&E employees who are struck by 

mainline trains is a growing issue and a cause for concern. It implies the guidance provided in 

the August 2004 SOFA Update (see Section 3.7.2 below) has had little or no effect.

Figure 3-8: Special Switching Hazard Struck By Mainline Trains Over Two Nine-Year Periods

3.7.2 Background

The SWG identified this issue in the August 2004 SOFA Update Chapter 4 titled SWITCHING 

FATALITIES – UNDERSTANDING AND PREVENTION. In this chapter, the update discussed 

cases in which employees were fatally struck by mainline trains. The update provided no 

recommendation except to say, “Other than general vigilance, awareness, and alertness to the 

switching environment, it is difficult to prescribe a preventive measure.”

The case numbers for the fatalities involving employees struck by mainline trains are shown in 

the Table 3-17 below. Pages 54 – 58 in Appendix A of this report provide the narratives for these 

cases.

Special Switching Hazard Struck By Mainline Train 

Over Two Nine-Year Periods

0

2

4

6

8

10

12

14

Fatalities

SSHST 7 13

Pre-SOFA (1992 - 2000) Post-SOFA (2001 - 2009)
39

Table 3-17 - 20 Cases For Employees Struck By Mainline Trains

Case Number Incident Date Railroad City State Job Description Age

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

FE-1993-13 13-Apr-93 CSX Dwale KY Freight 

Brakeman/Flagman

44

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.7.3 Statistical Background

Tables 3.18 shows fifteen of the 20 cases (75%) involving strikes by mainline trains occurred in 

the dark23

 23 For this study, the SWG defined “dark” as the period from 1⁄2 hour after sunset to 1⁄2 hour before sunrise.

. This is well above the percentage (40%) that occurred for other, non-Struck by 

Mainline Trains cases.
40

Table 3-18 Struck by Mainline Trains - Dark

Thirteen of the 20 cases (65%) involving strikes by mainline trains occurred during December, 

January, and February. This is more than twice the percentage (27%) for other, non-Struck by

Mainline Trains cases (see Table 3-19).

Table 3-19 Struck by Mainline Trains During Dec, Jan, and Feb

Appendix G in Volume II provides additional statistics on struck by mainline train cases.

3.7.4 Discussion

The issues with Struck by Mainline Trains were discussed thoroughly at the SSF and during 

SWG meetings. The following are issues and remedies for the railroad industry to consider.

3.7.4.1 Issue: Working Conditions May Compromise Employee Awareness

Working conditions, specifically darkness and winter months, compromise employee awareness. 

Darkness is clearly an issue: 75% of Struck by Mainline Trains fatalities occurred in the dark. 

Winter months are also clearly an issue: 65% of the Struck by Mainline Trains fatalities occurred 

from December through February. Together, 55% of Struck by Mainline Trains occurred in the 

dark and during winter months.

Risk to train-crew members increases in the dark, but they may not fully understand the extent to 

which “darkness” contributes to fatalities. Some job procedures or the design of personal 

protective equipment may not be adequate to address issues confronting train-crew members 

while working in the dark. Moreover, outer clothing worn during winter months can restrict 

hearing and peripheral vision; therefore, extra caution should be exercised.

Remedy: Use multiple warning methods. A single audible or a visual warning by itself may not 

be enough. A warning from one device can be misconstrued or forgotten by an employee highly 

focused on the task at hand. Use of multiple methods (radio, horn, bell, headlight, high-visibility 

clothing, etc.) reduces the likelihood for the employee to misinterpret or forget, and increases the 

chance the warning gets through to the employee.

3.7.4.2 Issue: Current Procedures and Training for Stopping Along the Mainline May Be 

Inadequate

Current procedures and training for stopping along the mainline to do work could be inadequate.

In particular, mandatory inspection procedures, such as locomotive, roll-by, and hotbox 

inspections, can put locomotive engineers and trainmen at risk when there is no safe location to 

conduct the inspection. Depth perception and recognition of train speed may contribute to a 

Struck by Mainline Train Cases Non-Struck by Mainline Train Cases

Cases occurring in the dark (78) 15 63

Total cases (179) 20 159

Percentage for cases in the dark 75% 40%

Struck By Mainline Train Cases Non-Struck by Mainline Train Cases

Cases occurring Dec – Feb (56) 13 43

Total cases (179) 20 159

Percentage for cases Dec - Feb 65% 27%
41

fatality when working in the dark due to impaired awareness of an approaching train. Struck by 

Mainline Trains is the most likely cause of fatal injuries to locomotive engineers.

Remedy: Develop, implement, and/or improve procedures for stopping to do work along 

mainline track.

• Encourage Train, Yard, and Engine (TY&E) employee use of current job briefing 

procedures for stopping to do work along mainline track. A job briefing in this situation 

should include this progression: 

o Determine a safe location to stop.

o Assess if inspection can be conducted from the field side (i.e., the safe side).

o Decide if necessary to dismount from the locomotive. 

 When an employee dismounts, dismount to the field side.

 If unable to dismount to the field side, do the following:

□ Identify all approaching on-track movements in immediate work location, 

if applicable.

□ Decide the safest time to dismount.

□ Stay out of the foul of the mainline track.

□ Be alert because adequate warning may not be provided.

□ Plan for the worst case scenario, and plan an escape strategy.

• Provide employees the discretion to determine the first safe location or time to conduct 

mandatory inspections.

3.7.4.3 Issue: Occasional Inadequate Communication Between Crew Members, Crews, 

Dispatchers, and Yardmasters

Communication is inadequate at times between crew members, crews, dispatchers, and 

yardmasters when stopped or when doing work on or near the mainline track. Lack of 

communication places crew members in peril of being struck by on-track movements. 

Remedy: Improve communication at all levels. Comprehensive and ongoing communication 

between all involved employees is vital before a crew member dismounts the locomotive to do 

required work. 

• Promote effective communication among and between crew members by utilizing 

established programs, such as Train Crew Resource Management24

• Employees should not leave the cab without first communicating intentions. Think 

outside the cab by communicating within.

.

• Encourage crews to communicate with, and provide warnings to, fellow crew members 

working outside of the cab.

 24 Appendix I provides materials on Train Crew Resource Management.
42

• Provide employees the discretion to establish a safe work zone that involves 

communication between that crew, the dispatcher and/or yardmaster, and other on-track 

movements.

3.7.5 Struck by Mainline Train – SOFA Safety Advisory Statement 2010

The SWG reemphasizes that communication is essential to eliminating fatalities related to 

Struck by Mainline Trains. Fatalities occur when employees are unaware of risks associated 

with doing work along mainline track – particularly at times of darkness and during winter 

months. Therefore, the railroad industry should insist upon consistent use of multiple methods to 

warn employees about oncoming on-track movements. Equally, warnings should be made to 

the approaching on-track movement of an employee’s location when a crew member is outside 

of the locomotive cab. In addition, the railroad industry should consider improving employee 

visibility when performing work on the ground.

Employees must use job briefing procedures before dismounting the locomotive or doing work 

along mainline track to establish a safe method for performing their work. When possible, 

employees must dismount to the safe side. Empower employees to establish a safe location 

when stopping and/or performing work when on or near mainline track. The railroad industry 

must support employees in the use of individual discretion as part of an effort to determine a 

safe location to perform work25.

 25 See Section 7.2 for the SWG position on empowerment and discipline.
43

3.8 Fatalities During the Second Hour of Duty

3.8.1 Finding

The number of SOFA fatalities during the second hour of duty is higher than any other on-duty

hour. The number of fatalities (30) occurring during the second hour of duty is surpassed by only

one SOFA category, SOFA 5. Figure 3-9 shows a bar chart displaying the number of fatalities 

against the number of hours the FE was on duty. The number of fatalities during the second hour 

is clearly the largest. The second hour of duty may correspond to the first hour of actual 

switching operations, considering, the first hour on duty is generally consumed with assembling 

the crew, reviewing paperwork, job and safety briefings, and traveling to the work site.

Figure 3-9: Hours on Duty Before Incident

Figure 3-10 suggests that this type of fatality is a growing issue.

Figure 3-10: Fatalities During the Second Hour of Duty Over Two Nine-Year Periods

Fatalities During the Second Hour of Duty

0

2

4

6

8

10

12

14

16

18

20

Fatalities

2nd Hour of Duty 12 18

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

 This roughly corresponds to the first hour of switching.
44

3.8.2 Background

This is a new finding that has not been covered in previous SOFA reports. The cases involving 

fatalities during the second hour of duty are shown in Table 3-20 below. Pages 66 – 71 in 

Appendix A of this report provide the narratives for these cases.

Table 3-20: Case Numbers for Fatalities During The Second Hour of Duty

Case Number Incident Date Railroad City State Job Description Age

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FE-2003-04 16-Feb-03 CSXT Syracuse NY RCL Operator 36

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

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

FE-2004-20 02-Sep-04 BNSF Clovis NM RCL Operator 26

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

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

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

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

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

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

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

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

3.8.3 Statistical Background

Tables 3.21 and 3.22 below suggest that many of these fatalities occur when yard crews leave the 

office and prepare for the first switching task of the day or road crews prepare their trains to 

leave the yard location.

Table 3-21 shows 18 of 30 cases (60%) during the second hour of duty occurred on yard tracks. 

This is about 14% higher than the percentage for cases during other hours of duty (46%).
45

Table 3-21: 2nd Hour of Duty, Yard Track

Cases During 2nd Hour of Duty Cases During Other Duty Hours

Cases occurring on yard track

(87) 18 69

Total cases (179) 30 149

Percentage for yard track 60% 46%

Table 3-22 shows 23 of 30 cases (77%) during the second hour of duty occurred while the FE 

was on the ground. Cases during the second hour of duty are almost 20 percentage points higher 

than for cases during the other hours of duty.

Table 3-22: 2nd Hour of Duty, FE on the Ground

Cases During 2nd Hour of Duty

Cases During Other Duty 

Hours

Cases with FE on the ground (110) 23 87

Total cases (179) 30 149

Percentage for FE on the ground 77% 58%

Appendix G in Volume II provides additional statistics on fatalities during the second hour of 

duty.

3.8.4 Discussion

This is a new finding that emerged through SWG deliberations that occurred after the February 

25, 2010 SSF.

Accounting for the time it takes for crews to assemble, review paperwork, conduct job and safety 

briefings, and travel to the work site, the second hour of duty essentially becomes the first hour 

the crew is actually on or about rolling stock or other equipment. This is when the crew then 

separates to begin switching operations. This means the first job or task for the day often occurs 

during the second hour of duty. Yard and road crews are often involved in these second-hour 

fatalities and have been fatally injured while performing their initial switching tasks.

3.8.5 Conclusion

The high number of SOFA fatalities (30) during the second hour of duty rivals other major 

SOFA issues such as SOFA 5 – Inexperienced Crew Members (32 fatalities) and Close/No 

Clearance (29 fatalities). Therefore, the industry should develop safety campaigns and other 

safety-related measures to make the workforce aware of this issue, and will lead to the 

elimination of second hour of duty fatalities.
46

4 NOTABLE STATISTICS AND OBSERVATIONS

4.1 Introduction

This chapter provides some additional statistics and observations about the 179 cases reviewed 

by the SOFA Working Group (SWG).

4.2 Classification of SOFA Cases

Table 4-1 provides a summary of the 20 SOFA categories and the number of cases in each 

category. The total in the fifth column on the table exceeds 179 because a SOFA case can qualify 

for more than one category. A chronological listing of all SOFA cases with their corresponding 

SOFA categories can be found in Appendix H.

Table 4-1: Classification of SOFA Cases

SOFA 

Classification Description

Pre-SOFA 

(1992-2000)

Post-SOFA 

(2001-2009) Total

Cumulative 

Percentage

SOFA5

FE had 1.5 years of experience or less or had 

inadequate training. 17 15 32 10.1%

SSHCC Special Switching Hazard: Close Clearance. 11 18 29 19.2%

SSHIH Special Switching Hazard: Industrial Hazard. 10 16 26 27.4%

SOFA3 Lack of or inadequate job safety briefing. 11 12 23 34.7%

SOFA1

Adjusting knuckles, adjusting drawbars, or installing 

EOT 15 6 21 41.3%

SOFA4

Mixing hand and radio signals or specific distances 

were not given. 17 3 20 47.6%

SSHST Special Switching Hazard: Struck by Mainline Train. 7 13 20 53.9%

SSHET

Special Switching Hazard: Employee Tripping, 

Slipping, or Falling 9 9 18 59.6%

SSHDR Special Switching Hazard: Derailment. 6 11 17 65.0%

SSHUC Special Switching Hazard: Unsecured Cars. 9 6 15 69.7%

SSHFR Special Switching Hazard: Free-Rolling Railcars. 8 6 14 74.1%

SSHMC Special Switching Hazard: Miscellaneous. 9 5 14 78.5%

SOFA2

Struck by equipment other than their own on yard or 

industry track. 10 3 13 82.6%

SSHUM

Special Switching Hazard: Unexpected Movement of 

Railcars. 9 3 12 86.4%

SSHEQ Special Switching Hazard: Equipment. 7 4 11 89.9%

SSHMV

Special Switching Hazard: Struck or struck by Motor 

Vehicle. 2 7 9 92.7%

SSHEV Special Switching Hazard: Environment. 3 4 7 95.0%

SSHFC

Special Switching Hazard: Failure to Confirm Route of 

Movement. 4 3 7 97.2%

SSHDA Special Switching Hazard: Drugs and Alcohol. 4 1 5 98.7%

SSHED

Special Switching Hazard: Electronic Device (Cell 

phone, MP3 player) 1 3 4 100.0%

TOTALS 169 148 317

4.2.1 Most Frequent PCFs

83 PCFs were assigned 372 times to the 179 cases, about two per case. Table 4-2 shows the 

PCFs used more than five times. Section 2.3.4 describes how the SWG used PCFs in the case 

reviews. A complete table of the PCFs used by the SWG can be found in Appendix E.
47

Table 4-2: Most Frequently Used PCFS

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

4.3 Type of Track

Figure 4-1: SOFA Fatalities by Track Type

Figure 4-1 shows 87, almost half of the 179 SOFA fatalities, occurred on yard track.

0

10

20

30

40

50

60

70

80

90

Type of Track

SOFA Fatalities by Track Type

SOFA Fatalities 87 44 40 8

Yard Industrial Line of Road Siding
48

4.4 Type of Movement

Table 4-3: SOFA Fatalities by Type of Movement

Movement Conventional RCL

Without 

Motive 

Power / 

Unknown Total

Equipment Being Pulled 38 1 39

Equipment Being Shoved 93 7 100

Equipment Free Running 3 2 31 36

Not Applicable 4 4

Total 134 10 35 179

Note: In four cases, the FE encountered an industrial hazard while walking and was not struck by 

train equipment. These cases are listed as “Not Applicable.”

Table 4-3 shows 100 fatalities occurred during shove moves, more than half. Table 4-3 also

includes a column on ten incidents involving Remote Controlled Locomotives (RCL). The SWG 

does not believe it is possible to form conclusions regarding RCL with only ten observations 

especially without good yearly data on the frequency of RCL use.

4.5 FE’s Location

Figure 4-2: SOFA Fatalities by Location

Figure 4-2 shows an FE was more likely on the ground than riding when fatally injured.

However, there were 69 cases when the FE was riding, 38.5% of the total.

0

20

40

60

80

100

120

SOFA Fatalities by Location

SOFA Fatalities 110 69

Ground Riding
49

4.6 FE Age and Experience

Figure 4-3: Age and Experience

Figure 4-3 shows that age and experience for fatally injured employees has declined from the 

Pre-SOFA period to the Post-SOFA period. The gap is for the two periods is especially large for 

length of service. The chart suggests that issues with SOFA 526

4.7 Fatalities in Cold Weather States During Winter and Other States During Summer

, employees with 1.5 years of 

experience or less, continue to present challenges to the railroad industry.

Figure 4-4 illustrates SOFA fatalities by month. January, July, and December are the only 

months with 20 or more fatalities. The SWG decided to look at these monthly statistics for cold 

weather states27 and other states (i.e., states not classified as cold weather states).

Figure 4-4: SOFA Fatalities By Month

Figure 4-5 shows there were 31 fatalities in cold-weather states during meteorological winter28

 26 See section 3.4 for more on SOFA 5.

(December, January, and February). Notice the bars for winter are relatively higher than other 

times during the year. The spike in December, the first month of winter, is almost five times 

27 For the purposes of this report, the SWG used these states as cold weather states: Maine, New Hampshire, 

Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania, Ohio, Indiana, 

Michigan, Illinois, Wisconsin, Minnesota, Iowa, Nebraska, North Dakota, South Dakota, Montana, Wyoming, 

Colorado, Utah, Idaho, and Alaska.

28 This report will use the word “winter” to refer to meteorological winter from hereon.

Age and Experience

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Years

1992 - 2000 19.5 12.6 46.1

2001 - 2009 12.3 10.9 43.5

Avg Length of Service Avg Time In Occupation Avg Age

0

5

10

15

20

25

SOFA Fatalities

SOFA Fatalities 21 12 10 12 13 17 20 12 14 16 9 23

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
50

higher than the low months in June, August, and November. Table 4-4 compares the fatalities in 

these states to other months of the year. Cold-weather states accounted for more than half (55%) 

of the fatalities in winter and less than half (41%) during other months of the year. This 

difference suggests there is increased risk in cold-weather states during winter. The median 

temperature for these incidents was 21 degrees Fahrenheit. July, the hottest month of the year, 

also has a relatively high number of fatalities compared to other months.

Figure 4-5: SOFA Fatalities By Month For Cold-Weather States

Table 4-4: Fatalities in Cold-Weather States

Dec, Jan, Feb Other Months

Fatalities Cold Weather States (81) 31 50

Fatalities All States (179) 56 123

Percentage For Cold Weather States 55% 41%

Conversely, Figure 4-6 shows there were 34 fatalities in other states (i.e., states not classified as 

cold weather states) during meteorological summer29

 29 This report will use the word “summer” to refer to meteorological summer from here on.

(June, July, August). The bars for summer 

are relatively higher than other times during the year. The spike in June, the first month of 

summer, is almost three times higher than the low months in February and March. Table 3-36 

compares the fatalities in these states to other months of the year. Other states accounted for 

more than half (69%) of the fatalities in summer and less than half (49%) during other months of 

the year. This difference suggests there is increased risk in other states during summer. The 

median temperature for these incidents was 80 degrees Fahrenheit. January, the coldest month of 

the year, also has a relatively high number of fatalities compared to other months.

0

2

4

6

8

10

12

14

81 SOFA Fatalities in Cold Weather States

SOFA Fatalities 10 7 5 6 7 3 9 3 7 7 3 14

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
51

Figure 4-6: SOFA Fatalities By Month For Other (Non-Cold-Weather) States

Table 4-5: Fatalities in Other (Non-Cold-Weather) States

Jun, Jul, Aug Other Months

Fatalities For Other (Non-Cold Weather) States 34 64

Fatalities All States 49 130

Percentage For Other States 69% 49%

The above Figures 4-5 and 4-6 suggest the onset of cold weather (December in cold-weather 

states and January in other states) may create conditions for increased risk of fatalities. Figures 

4-5 and 4-6 also suggest the onset of hot weather (June in other states and July in cold-weather 

states) may create conditions for increased risk of fatalities. The railroad industry may want to 

consider additional preparation and education of the workforce on adapting to changing 

conditions in summer and winter. Appendix H provides additional information on fatalities in 

winter and summer.

4.8 High Risk Holiday Periods

Historically the SWG has been monitoring the high risk periods for holidays for some time.

Particularly the following two high risk periods.

• One week period bracketing Independence Day (July 4th.).

• Three-week period bracketing Christmas (December 25th) and New Year’s Day 

(January 1). 

Table 4-6 shows high fatalities for December and July, the four “high-risk” holiday weeks for 

fatalities. There were 19 fatalities during the four high-risk weeks from 1992 to 2009. The 

percentage of weeks when there was a switching fatality, 26.4%, is higher during the high-risk 

weeks than the percentage for the other 48 weeks, 18.5%.

0

2

4

6

8

10

12

14

98 SOFA Fatalities in Other States

SOFA Fatalities 11 5 5 6 6 14 11 9 7 9 6 9

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
52

Table 4-6: SOFA Fatalities During the Four High-Risk Weeks

Four HighRisk Weeks 48 Other Weeks

Weeks with a SOFA fatality (179) 19 160

Total number of weeks (936) 72 864

Percentage for weeks with SOFA 

fatalities 26.4% 18.5%

It is not clear that the higher rate of fatalities during the high-risk weeks is due to conditions that 

are unique to the holidays. The higher rate of fatalities could be due to the winter and summer 

effects which are addressed immediately above. Since the SWG cannot determine if the 

“holiday” effect is separate and independent of the “seasonal” effects discussed above, it decided 

to monitor this issue rather than issue a finding on it.
53

5 SOFA-Defined Severe Injuries

5.1 Introduction

In addition to switching fatalities, SOFA-defined severe injuries are a source of considerable 

harm to Train, Yard, and Engine (TY&E) employees. 1,522 severe injuries -- 201 of which were 

amputations (13.2 percent) -- occurred, 1997 through 2009, to these employees. 

Incidence has declined over the years, with the appearance of stages, as shown by three shaded 

sections in Figure 5-1. In 2010, there were 51 severe injuries January through October v. 42 in 

the corresponding period of 2009. (Ten months of 2010 was the most up-to-date period available 

at time of publication.) However, based on ten months, it would be premature to make any 

prediction about the number of injuries that will occur in 2010, full-year. Or years after.

Figure 5-1: SOFA-defined Severe Injuries by year, 1997 through October 2010

(Note: 1997 is the first year these injuries can be defined based on the interests of SWG)

5.1.1 Chapter Overview

This chapter discusses SOFA-defined severe injury topics: importance, definition, SOFA 

Working Group (SWG) interest, data potential for further understanding of switching fatality 

issues, recent declines, and seasonality. Throughout, focus is given to possible relationships with 

switching fatalities. Descriptions by selected attributes and track locations are provided in 

Appendix J.

5.2 Importance of Severe Injuries

Severe injuries can involve major trauma. As mentioned, while in recent years these injuries 

have declined, continuing existence indicates the importance of safety efforts devoted towards 

elimination. As with switching fatalities, SWG maintains zero tolerance to severe injuries, the 

goal being complete elimination.

SWG has interest in factors causing these injuries. An important question -- not easily answered 

because of data considerations given the interests of SWG -- is whether such factors are similar 

to those causing switching fatalities? Translated into preventive action, the issue becomes, will 

SOFA findings ‘spill over’ to eliminate severe injuries? Or are additional efforts required? 

Again, data considerations, such as not being able to assign Possible Contributing Factors (PCF)

codes, make some answers problematic. 

139 137 135 139 140

123 114 123 122

100 110

87

53 51

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
54

5.3 Definition of SOFA-defined Severe Injuries

1997 is the first year severe injuries, as defined by SWG, can be determined as a result of 

additional anatomical specificity in FORM FRA F 6180.55a (the’55a’) coding, and development 

of seven circumstance codes that allow some sequencing of events preceding an injury. 

Switching fatalities based on investigations can be determined further back. Thus, the SWG 

study and surveillance period for severe injuries is five-years shorter than for fatalities. 

For compatibility with switching fatalities, SWG included only TY&E employees, believing 

these employees were the most likely to engage in similar switching operations. Severe injuries, 

based on a verifiable diagnosis, were formally defined by SWG as (1) potentially life 

threatening; (2) having a high likelihood of permanent loss of function, permanent occupational 

limitation, or other permanent disability; (3) likely to result in significant work restrictions; and 

(4) involving a high-energy impact to the human body. Severe injuries include amputation, 

dislocation of the neck, loss of eye, electric shock or burn, and fracture to any bone except the 

lower arm, fingers, foot, and toes (Table 5-1). These injuries include only those required to be 

reported to the FRA. 

Table 5-1: Definition of SOFA-defined Severe Injuries

Type Body Location

Fracture Upper arm, upper leg, knee, lower leg,

ankle, heel, eye, skull, neck, spine,

upper back, lower back, shoulder,

collar bone, rib/rib cage, hips,

and multiple fractures

Amputation Any body part

Dislocation Neck

Loss of eye One or both

Electric

Shock/burn

Eye, ear, nose, mouth/teeth, skull, and neck

Other burn Eye, ear, nose, mouth/teeth, skull, and neck

Illnesses to TY&E employees potentially meet the SOFA-defined criteria for severe injuries, 

with the one exception of resulting from a high-energy impact. However, SWG has not studied 

these illnesses, or included illnesses in counts of severe injuries. Such illnesses would include 

heat/sun stroke, freezing/frostbite, noise-induced hearing loss, poisoning, and dust diseases 

affecting the lungs.
55

Most SOFA-defined severe injuries involve fractures (83 percent). The distribution of severe 

injuries by nature of injury, 1997 through 2009, is shown Table 5-2.

Table 5-2: SOFA-defined Severe Injuries by Nature of Injury, 1997 through 2009

Nature of Injury FRA Nature of Injury Code Number Percent (%)

Fracture #70 1,263 83.0

Amputation #80 201 13.2

Other Burns #50 45 3.0

Electric Shock/Burns #40 10 0.6

Dislocation #60 3 0.2

totals 1,522 100.0%

5.4 SOFA Interest in Severe Injuries

In issuing its first switching fatality report in 1999, SWG’s interest in severe injuries developed 

based on:

1. Type of information available about severe injuries, recognizing that the associated events 

are not investigated or reported like switching fatalities;

2. Extent to which the available information allows determination of whether these injuries 

have a similar PCF basis as switching fatalities -- or whether different processes are 

involved; and

3. Whether there is potential for making findings in operating procedures to affect prevention.

With those interests in mind, and its knowledge gained from studying switching fatality events, 

SWG undertook an analysis of SOFA-defined severe injuries in 2000 and published a report in 

July 2001.30

As an example of possible fatality-event linkage, historically amputations comprise about 13 

percent of all severe injuries. In particular, a lower body amputation resulting from equipment 

movement may involve SOFA 1-5 and/or SSH. Indeed, the difference between a fatality and a 

severe injury may only involve prompt medical intervention. Other examples could be given to 

illustrate that some severe injuries may involve SOFA 1-5 and/or SSH. Thus, SOFA findings 

may have a ‘spill over’ effect resulting in prevention of some potential severe-injury events, and 

even injuries of lesser severity affecting employees engaged in switching operations. But, again 

because of data limitations, difficulty exists in estimating how many such events have been, or 

could be, prevented.

Given the nature of information available (i.e., not investigated like fatalities), SWG 

could not conclusively link SOFA Recommendations to severe injuries, but published its results 

in the interest of railroad safety. However, this was not interpreted as meaning that SOFA 1-5 

Recommendations do not have value in severe-injury prevention. (Note: At the time of this 

report (2001), SWG had not formally developed a classification system for Special Switching 

Hazards (SSH). Development of the SSH classification system began in 2002. Hence, SSHs were 

not explicitly analyzed in its injury report, although there was mention of ‘close clearances.’) 

In publishing its injury report, SWG did not offer any special preventive measures other than 

recognition that these injuries occur with a frequency warranting caution among employees, and 

scrutiny among railroads and government officials, as well as the affiliated safety community. 

 30 See Severe Injuries to Train and Engine Service Employees: Data Description and Injury Characteristics. July 

2001. Available at: http://www.fra.dot.gov/us/content/1781 [accessed September 2010]
56

Since the SWG 2001 injury report, SWG could only monitor, as in its quarterly updates, the 

incidence of severe injuries and provide descriptive information.

5.5 Information Difficulties in Determining Causes of SOFA-defined Severe Injuries

Table J.1 (See Appendix J) displays the information available about severe injuries, based on 

FRA Form F 6180.55a. A short narrative description may be provided if circumstances cannot be 

fully captured in coded information. As mentioned above, unlike switching fatalities, most 

severe injuries are not investigated. In issuing its SWG 2001 report, SWG said:

The SOFA Working Group has looked at the injury data from the perspective of the 

knowledge gained from its detailed investigation of Fes [fatalities, employees] where the 

circumstances surrounding, and leading up to, a FE where {sic} identified. The SOFA 

Working Group realizes that serious [severe] injuries are not investigated the way FEs 

are; hence, it is not always possible to identify these circumstances. The implication of 

this is clear: it is not possible for the SWG to tell if one or more of its five safety 

recommendations applies to a particular Serious [Severe] Injury event.31

In saying “it is not always possible to identify these circumstances” SWG was not suggesting 

injury information is not of value or incomplete. Rather, for the issues of interest to SWG, as 

assignment of PCFs and classification as SOFA 1-5 and/or SSH, determination could not be 

made. Appendix J contains a discussion (Using FORM FRA F6180.55a Information about 

Severe Injuries, and Further Analysis, to Better Understand Switching Fatalities) about 

using FRA Form F 6180.55a information to potentially better understand switching fatalities and 

issues relevant to these fatalities, as well as suggestions for further analyses.

5.6 Declines in SOFA-defined Severe Injuries

In 2002, SOFA-defined severe injuries began to decline although not consistently year-to-year

(Figure 5-1). For the years, 1997 through 2001 severe injuries averaged 138.0 per year. For 2002 

through 2007, an average of 115.3 per year occurred. In 2008, there were 87 severe injuries. 

Then in 2009 injuries declined to 53, a 13-year low. 

Of interest to SWG is why this decline occurred. Currently, SWG cannot provide an answer. A 

similar decline, although the timing pattern is somewhat different, is also evident in the larger 

casualty series (not including deaths) involving TY&E employees of which SOFA-defined 

severe injuries are a subset (Figure 5-2). 

 31 ibid
57

Figure 5-2: SOFA-defined Severe Injuries v. All Reportable Casualty (but not deaths), TY&E employees, 

1997 through 2009 

From 1997 through 2009, SOFA-defined severe injuries have averaged 3.9 percent of this larger 

casualty series to TY&E employees (Table 5-3). About this average, there is annual variation, 

with a low of 2.8 percent in 2009; and a high of 4.4 percent in 2007. 

Table 5-3: SOFA-defined Severe Injuries as Percentage of All Reportable Casualty to Train and Engine 

Service Employees, 1997 through 2009

Year SOFA-defined

Severe Injuries

All

Reportable

Casualty

Percent

(1) (2) (3) = (1) / (2)

1997 139 3,468 4.01%

1998 137 3,626 3.78%

1999 135 3,814 3.54%

2000 139 3,878 3.58%

2001 140 3,547 3.95%

2002 123 3,013 4.08%

2003 114 2,923 3.90%

2004 123 2,890 4.26%

2005 122 2,800 4.36%

2006 100 2,474 4.04%

2007 110 2,506 4.39%

2008 87 2,186 3.98%

2009 53 1,907 2.78.%

totals 1,522 39,032 3.90%

3468

3626 3814 3878

3547

3013 2923 2890

2800 2474 2506

2186

139 137 135 139 140 1907

123 114 123 122 100 110

87

53

0

50

100

150

200

250

300

350

0

1000

2000

3000

4000

5000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

all other injuries/illnesses (but not deaths) severe injuries
58

Attempt has been made to determine if some severe injury types declined more than others, thus 

potentially providing insights into reasons for the overall decline, particularly in 2008 and 2009. 

Indication does exist for variation for some severe injury types based on proportionality. 

Proportional variation by track type exists (Appendix J, Table J.8). There is also proportional 

variation among event types (Appendix J, Table J.9) and states (Appendix J, Table J.10). 

However, such proportional differences appear too small to isolate a specific cause (s) internal to 

railroad operations. 

Possibly the decline is associated with broad-based economic conditions as reflected by overall 

activity levels (e.g., train and switching miles, freight car loadings). As an observation, declines 

in severe injuries began in 2002 and are acute in 2008 and 2009. These years coincide with 

downturns in overall economic activity, although the decline in the larger casualty series began 

earlier in 2001 (Figure 5-2). More conclusive evidence of an economic role likely would have to 

come from observing injury levels in future years having normal economic conditions, and from 

understanding long-term, operational trends which may also cause severe injuries to decline. As 

well, any discussion of reasons for the decline should consider operational change, and safety 

program effectiveness.

Notwithstanding, as mentioned, SWG cannot offer conclusive reasons why SOFA-defined severe 

injuries have declined. Declines appear to be broad based across railroads and regions. SWG 

intends to continue its interest into reasons for the decline. SWG invites members of the safety 

community to analyze the decline. Primary focus, however, should be proactive in trying to 

prevent the severe-injury events still occurring, in accordance with SWG’s goal of zero 

tolerance. 

5.7 Seasonality and Winter Months

December, January, February, and March historically have relatively high counts of severe 

injuries, but all months have risk for SOFA-defined severe injuries (Figure 5-3). While likely 

winter conditions play a role, all of the reasons for increases in these months are not known. 

Figure 5-3: SOFA-defined Severe Injuries, by month, 1997 through 2009

173

150 136

113 100 102 104

129 129 115 129 142

0

50

100

150

200

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
59

5.7.1 Cluster of Slipped, Fell, Stumbled, etc., Injury Types...Increases in winter Months

The composition of severe injuries by event type contains a large cluster. There were 640 SOFAdefined severe injuries, 1997 through 2009, resulting from ‘slipped, fell, stumbled, etc.’ (FRA 

Event Codes #51-54, and 70) -- 42 percent of the total 1,522 injuries occurring during this period 

(Figure 5-4). Other clusters of severe injuries by event types are much smaller (Table J-9).

Figure 5-4: Composition of 1,522 Severe Injuries: Slipped, Fell, Stumbled, etc. v. All Other 

Types, 1997 through 2009

Winter appears to be a factor in ‘slipped, fell, stumbled, etc.’ events. During December, January, 

February, and March, 1997 through 2009, the percent of this injury type is 48 v. 38 percent for 

other months (Figure 5-5). 

Figure 5-5: Severe Injuries Attributable to Slipped, Fell, Stumbled, etc., by month, 1997 

through 2009

882

90

74

55

40 37 36 36

53 49 45 51

74

52%

49%

40%

35% 37% 35% 35%

41% 38% 39% 40%

52%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

`

640

882

Slipped, etc. All Other
60

5.8 Going Forward

SWG at times has encountered difficulties in answering safety questions about severe injuries. 

Some of these difficulties were not based entirely on available data. Time and resources 

available to SWG has limitations. Given its charge, most of SWG’s time and resources are used 

to review and discuss fatalities. SWG invites other safety groups to use severe injuries as a way 

of understanding safety issues and hazards.
61

6 EVALUATION OF THE SOFA WORKING GROUP FOR THE 

IMPLEMENTATION OF SOFA FINDINGS

6.1 Introduction

In preparation for the SOFA Working Group (SWG) reconvening in January 2009, the Chair of 

the working group contacted past SWG members, one of whom represented the FRA Office of 

Research and Development (R&D). The SWG requested research and evaluation support from 

R&D, and specifically asked for implementation support to develop and refine strategies for 

dissemination of SOFA findings and implementation of action ideas in the railroad industry.

Upon release of the 1999 SOFA Report, the railroad industry responded with the implementation 

of safety programs to promote the use of the SOFA findings and recommendations; however, the 

extent that these efforts have been sustained or had an impact over the past 10 years is unclear. 

To support the current formation of the SWG, R&D assembled a professional team with 

backgrounds in education, human-factors research, program development, and utilizationfocused evaluation32

6.2 Evaluation Goals

. The evaluation team operated in support of the SOFA goal of Zero 

Fatalities with a purpose to foster (a) the use of SOFA findings and (b) the implementation of 

effective safety practices. 

Using a case study approach, the evaluation team studied the SOFA process and immersed itself 

in the SWG activities by embedding a team member within the group. In addition to providing

technical support for 2010 SOFA Report, the evaluation team aimed for the following goals:

• Understand the implementation of past SOFA findings. 

• Create a SOFA theory of action, represented in a logic model.

• Clarify and describe SWG process.

• Develop stakeholder engagement strategies for implementation of new and prior SOFA 

findings (i.e., The Five Lifesavers).

• Facilitate use of SOFA findings in the railroad industry.

These evaluation goals are connected inextricably to the intended use of the SOFA findings in 

the railroad industry to reach the ultimate goal of Zero Fatalities.

6.3 Background

The goal of the 1999 SOFA Report was to make recommendations that, when implemented 

would reduce the incidence of fatalities and any related injuries in switching operations. 

Accordingly, the recommendations focused on actions that could be taken by the FRA and the 

railroad industry to improve the safety of switching operations. The SWG identified the

 32 Patton, M.Q. (2008). Utilization-Focused Evaluation (4th ed.). Thousand Oaks, CA: Sage.
62

following five approaches to improving safety that “can impact the occurrence of unsafe acts, or 

latent conditions, that contribute to incidents” (1 - 5) and promote a culture of safety in the 

workplace.

• Improved design of equipment used in yards, rolling stock, worksite and layout.

• Improved training or communication procedures, such as job briefings.

• Revised or re-emphasized rules and procedures.

• Improved track or equipment maintenance.

• Modifications to management policy and workplace culture.

Safety culture is the combinations of attitudes, values, beliefs, norms, and perceptions that 

employees at every level of an organization share in relation to safety, safe behaviors, and 

practices (Clarke, 2000). It refers to the extent to which individuals and groups will commit to 

personal responsibility for safety; act to preserve, enhance and communicate safety information; 

strive to actively learn, adapt and modify (both individual and organizational) behavior based on 

lessons learned from mistakes; and be held accountable or strive to be honored in association 

with these values (von Thaden, Kessel & Ruengvisesh, 2008, adapted from Wiegmann, Zhang, 

von Thaden, Sharma & Mitchell, 2002:8). This definition combines key issues such as personal 

commitment, responsibility, communication, and learning in ways that are influenced strongly by 

processes instantiated by upper-level management, but also influence the behavior of everyone in 

the organization (cf. Wiegmann et. al, 2004). 

Overall a safety-culture may drive resource management decisions, shape organizational climate, 

and influence the development of organizational processes. Safety culture represents a complex 

understanding wherein an organization must evaluate its strengths and vulnerabilities to promote 

the creation of a consistent, positive safety culture. 

The key in any safety-culture improvement program is to develop effective measures to evaluate 

the current state of a particular safety culture, as well as to determine whether interventions have 

been effective in achieving a desired cultural change (Coplen, 1999). Therefore, indicators of 

safety culture within an organization first must be identified and then be measured specifically 

before any training or procedural changes should be introduced and expected to be accepted 

within the organization. Without identification and measurement of the safety-culture baseline, 

unidentified barriers may hinder effective implementation of safe practices (Coplen, 1999). This 

assertion of how to make change in safety practice when implementing new safety programs 

provides insight into why the degree of change expected by the 1999 SWG did not occur, and in 

what way the 2010 SWG should proceed with the railroad industry to promote change as a result 

of the 2010 findings.

6.4 Evaluation Standards

A safety program delivered through education, outreach, or accountability is not considered a 

means to a predefined end, but rather, a practice that has different, sometimes conflicting,

meanings for various stakeholders. A safety program evaluation provides illumination, evidence, 

and understanding to foster informed decisions about complex and dynamic programs and their 

contexts. To acknowledge this ambiguity, evaluation criteria should derive from stakeholder 

issues, emphasizing the intended change as an innovation within specific contexts. In 

cooperation with stakeholder collaboration, an evaluator can provide knowledge, foster 
63

understanding, and facilitate improvement toward the desired goal or change. The standards of 

professional evaluation practice, the Guiding Principle33 and the Program Evaluation 

Standard34

Under certain conditions, an evaluator may assist programs in adapting program implementation 

through presenting suggestions for altering program design. The design and planning processes 

link to ongoing improvement through analysis of implementation strengths and weaknesses. This 

describes the role of the evaluation team, and the standards by which it made its assertions about 

the SWG process.

, suggest evaluators operate with greater independence and in stakeholder interest, and 

therefore support the evaluator role as facilitative. 

6.5 Evaluation Approach, Method, & Phases

The evaluation team used a case study approach, retrospective and prospective in scope, looking 

at current effects of previous SOFA reports to (a) understand the potential causes of those effects 

and (b) inform future planning and potential trajectories for action of the SWG. The evaluation 

team employed multiple research methods, including document analysis, logic models, 

participant observation, individual SWG member interviews, and stakeholder review, in a 

systematic and responsive manner during the evaluation period of 15 months. 

The following table outlines the key evaluation activities with the SWG since January 2009.

Table 6-1 Key Evaluation Events Timeline with the SWG

SWG

Reconvene

Logic 

Model

SWG 

Member 

Discussions

Theme

s

Logic 

Model

SWG 

Reunion

Process 

Eval 

Report

Logic 

Model

SSF 

Prep 

Task 

w/ 

SWG

SSF 

Planning

& Event

SSF Theme

Analysis

SSF Report Outline

SSF Report Draft

SOFA Finding Report Release

Jan Feb Jul Aug Sept Oct Dec Jan Feb Mar May Jun Dec

2009 2010

6.5.1 Document Analysis of Past Implementation Strategies

The first phase of the evaluation involved understanding the history of SOFA and what happened 

since first report released in October 1999. The findings within the1999 SOFA Report were 

disseminated widely to the railroad industry using multiple implementation strategies, but not 

without difficulties.

Following the release of the 1999 SOFA Report, SWG labor members reported to the SWG that 

the Five Major Safety Recommendations were being implemented but were being used as a basis 

of elevated discipline, which was not the intent of the “the Five Lifesavers”. The process for how 

the Lifesavers should be implemented became a focus of the SWG. Consequently, SWG 

developed guidelines, which were influenced by the 1999 edition of the Program Evaluation 

Standards, to assist in more effective implementation. (See Appendix K for further description of 

the SOFA Implementation Guidelines for Five Major Safety Recommendations.)

Further document analysis involved systematic review of meeting notes from a series of 30-

person teleconferences held after the 1999 SOFA Report release, during 2000 and 2001. The 

 33 American Evaluation Association (2004). Guiding Principles for Evaluators. http://www.eval.org/Publications/

GuidingPrinciples.asp

34 Joint Committee on Standards for Educational Evaluation (1994). The Program Evaluation Standards. Thousand 

Oaks, CA: Sage.
64

analysis of these notes revealed eight prominent categories of activities reportedly being 

implemented by the railroad industry during that time. The following table presents the activities

organized by purpose, described using example products or program outputs, and categorized by 

outcomes possibly demonstrated from those strategies. 

Table 6-2: 2000-01 Reported Implementation Activities Related to the SOFA Recommendations

Strategy Purpose Example Description Use

SOFA Promotional Items - Magnets, stickers, and “5 Lifesaver” cards

- SOFA-created video (or carrier-created videos)

- Poster campaign, “Five-Lifesavers”, in yard offices

- Outreach 

- Educational

SOFA Events - National SOFA Day

- SOFA Action Plan within service units

- SOFA Coordinators who are past SWG members or safety leaders

- Outreach

- Educational

Safety Policy - SOFA recommendations adapted into operating and 

safety rule books and testing 

- Three-point protection process

- Safety Committees comprised of employees and management

- Accountability

Performance 

Measurement

- Switching yard audits or “Safety Review”

- Efficiency testing

- Work practices observations

- “Ride-alongs” by managers

- Accountability

- Outreach

Safety Training 

Programs

- TY&E employee training program 

(incorporate the SOFA report and video) 

- Crew Resource Management with focus on the “Five Lifesavers” 

- Supervisor classes include a SOFA segment/module

- Operating Department Rules/CRM/SOFA class for employees

- Educational

- Accountability

Mentoring - Orange armbands worn by employees with less than one year of 

service who may need special attention

- Formal employee-to-employee mentoring established

- Educational

- Accountability

Communication 

(to stakeholders)

- Meetings for employees, carrier- and labor-supported 

- “SOFA Safety Blitz” to employees throughout carrier system

- Correspondence to employees from carrier leadership

- Correspondence to employee families from carrier leadership

- Correspondence to customer from carrier leadership

- Newsletters to employees

- Outreach

- Educational

- Accountability

Signage - Proper signage, particularly close or no clearance signs, be 

maintained by customer

- Accountability

The analysis revealed the extent to which any of these strategies had an impact or were sustained 

during the following decade was unknown and would require further inquiry to understand. 

Without the establishment of monitoring systems at the time when reported program activities 

were implemented, no data were captured to track and evaluate the impact and sustainability of 

such programs. 

However, this evaluative review of past implementation activities suggests that future safety 

program planning efforts should include the development of methods to track and monitor 

implementation programs for ongoing evaluation and program improvement by railroad industry

stakeholders. 
65

6.5.2 Logic Modeling of SWG Theory of Action

In spite of the aforementioned strategies and guidelines for implementation, which appear to 

have held the attention of the railroad industry for a period of time, the number of switching 

operations fatalities eventually accumulated to a critical point when the request was made for the 

SOFA Working Group to reconvene in 2009. 

A concurrent request emerged for the evaluation team to inform and guide alternative 

implementation approaches that contribute to the greater, more sustained, utilization future 

SOFA findings. In February 2009 and at the invitation of the SWG, an evaluation team member

attended the SWG meeting in Chicago to facilitate conversation about how to attain greater and 

more lasting impact with the 2010 report. As a first step for the SWG, the evaluation team 

recommended clarification of the intended actions and outcomes the SWG that would achieve its 

goal of Zero Fatalities. The evaluation team then visually represented the SWG process as a 

theory of action logic model for the group to further refine.

Logic models assist in more effective planning, implementation, evaluation, and communication 

within programs and across stakeholders. The visual representation describes logical linkages 

among resources, activities, outputs, audiences, and outcomes related to a specific problem or 

situation. Once a program has been described in terms of the logic model, critical measures of 

performance can be identified. Further, the model helps to identify partnerships integral to 

enhancing program performance. First steps involve assessing the situation and articulating the 

priorities. The SWG discussed its theory for action and reviewed four iterations of a logic model 

through its process; the final version is shown in Figure 6-1. 
66
67

6.5.3 Process Evaluation

After articulating a theory of action through a logic model, the evaluation team sought to 

understand and validate the SWG process from an external perspective. The evaluation team

captured, formally and systematically, the lessons learned about past implementation of SOFA 

findings by key stakeholders in railroad industry as they emerged during the SOFA process. The 

evaluation team observed and participated in SWG meetings, and documented the SWG current 

processes and reflective actions.

The evaluation team concluded that the SOFA process is systematic, rigorous, comprehensive, 

and objective. Furthermore, the findings of the SWG are valid, significant, and worthy of the 

railroad industry’s thoughtful attention and bold response. 

These conclusions were 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. (See Appendix L for the Process 

Evaluation Report.)

6.5.4 SWG Interviews

A next step was to identify the current situation and priorities for the SWG in its considerations 

for the implementation and utilization of its SOFA findings. To this end, an evaluation team 

member conducted individual, face-to-face interviews with nine of the 10 SWG members present 

at the August 2009 SOFA meeting; three interviews were with members who had served 

previously as a SWG member. 

Members revealed historically challenging conditions in which the railroad workers operate. The 

productivity pressures within the railroad industry are intrinsic and systemic. An authoritative 

management style with regard to rules has fostered a resistance on the part of labor to support 

changes in worker practices. Subsequently, the litigious and defensive cycle of worker 

performance comprises the work environment. 

The “Just get it done” work ethic and the “It won’t happen to me” mind-sets were prevalent in 

the railroad industry and presented themselves as persistent barriers to the adoption of the 1999 

SOFA “Five-Lifesavers” recommendations; therefore, they arise as the dominant challenges in 

designing the implementation plan for the 2010 report. Most “ballast level” SOFA members 

reported changing their own behaviors as a result of being on SWG. The results progressively 

focused a key inquiry question to guide the current SWG through its work: What can the SWG 
68

do to help facilitate this behavior change and improve safety culture in switching operations 

more broadly?

6.5.5 SOFA Working Group Reunion

A meeting that included participation of the past and present SWG members provided an 

opportunity for a reflective discussion of implementation issues through an interactive review of 

the SWG interview themes from the previous meeting. Members at the reunion validated the 

themes and shared their personal experiences and multiple perspectives on the persistent 

implementation barriers. 

The past SWG members discussed their impressions of why the last SOFA report findings, 

which were issued explicitly as recommendations to the railroad industry, were not adopted as

they had intended. Through an expertly facilitated discussion by an evaluation team member, 

insight was gained as to why recommendations may have been co-opted into rules over time: 

They read like rules.

A shift in focus was posited regarding the power of not issuing explicit recommendations, but 

reporting simply the findings. However, the caveat of this process was that the SWG would have 

to strive to involve key stakeholder groups early – prior to report release. 

A conclusion and assertion from the process evaluation was the importance and critical need to 

involve key stakeholders during the process of the SWG before the report was written, finalized, 

and released to the railroad industry. The goals of involving stakeholders, asking for their 

participation, and collaborating with key stakeholders were to create a buzz, prepare the railroad 

industry for the forthcoming report, and encourage the stakeholders to generate ideas for how to 

implement the findings. 

6.5.6 SOFA Safety Forum

After the SWG reunion, ideas were generated around starting the outreach campaign to the 

railroad industry, such as through a press release, to start the buy-in process early. Furthermore, 

an event was suggested that would engage key stakeholders in the preliminary findings. This 

event could structure the stakeholder engagement through a mix of whole group and small group 

activities. 

The event goals would be three-fold: (a) to preview the SOFA findings, (b) to announce the 

forthcoming 2010 Report release, and (c) to encourage stakeholder consideration of appropriate 

and specific actions they will want to take in response to the SOFA findings. The underlying 

importance is for stakeholder involvement during the process and to build capacity for use of the 

findings. Among other advantages, this utilization-focused approach would recognize that 

solutions are formulated best in context, and acknowledge that the most appropriate fix for a 

given problem would likely vary from carrier to carrier and site to site.

Consequently, the SWG decided to convene an event that became known as the SOFA Safety 

Forum (SSF) was held on February 25, 2010. Fifty-five senior safety leaders representing 19 

railroad-industry organizations participated in the SSF (See Table 6-3). 
69

Table 6-3 SOFA Safety Forum (SSF) Attendee Affiliation List

Washington, D. C., February 25, 2010

Association of American Railroads (AAR)

American Short Line and Regional Railroad Association (ASLRRA)

Amtrak 

Anacostia & Pacific

Brotherhood of Locomotive Engineers and Trainmen (BLET)

Burlington Northern Santa Fe (BNSF)

Canadian National (CN)

Canadian Pacific (CP)

CSX

Federal Railroad Administration (FRA)

Iowa Interstate

Kansas City Southern (KCS)

Norfolk Southern (NS)

OmniTRAX

RailAmerica

Union Pacific (UP)

United Transportation Union (UTU)

Watco Companies

Wheeling & Lake Erie

Engagement Approach

The evaluation team played an instrumental role in facilitating and guiding the event planning 

and execution. The small-groups (a) affirmed the credibility of the SOFA finding, (b) identified 

related issues, (c) explained potential barriers, and (d) discussed action ideas for utilizing the 

findings in the railroad industry. 

The small groups were balanced with representatives from labor, management, and government 

to mirror the composition of the SWG and to foster equitable discussion. Five small groups 

consisted of 14 persons: 11 attendees, 2 SWG representatives, and 1 facilitator. The evaluation 

team members served as the small-group facilitators. Two SWG members participated in the role 

of SWG representative present to clarify and listen to any issues or questions regarding the 

SOFA process or switching fatality data cases. 

A note-taker captured the breadth of each group discussing with any attributions made 

anonymous and any identities confidential in analysis, reporting, and reference to themes. The 

transcribed notes were verified for accuracy by the facilitators and SWG representatives present 

at their respective tables. Once verified, the evaluation team systematically and iteratively 

analyzed the content deductively to reveal themes to code the data. Then the evaluation team reanalyzed the content using previously identified themes to code the data inductively. Table 6-4 

organizes the data themes by the key SOFA finding discussed in each small group and by the 

three areas of discussion. (See Appendix K for the transcripts of the small-group notes, which 

have been made anonymous, and are organized by theme.)

The SWG achieved the goals it set for the forum, and considered the implications for the railroad 

industry when asserting or recommending a particular practice or policy. The SWG deliberated 

the SSF themes in finalizing their report and in planning it release to the railroad industry. The 
70

process that revealed itself through the reflection, participation, and direction of the SWG 

demonstrates potential as a model for other industry and safety programs. (See Appendix K for a 

table that summarizes the SSF process through action phases and illustrated by guiding questions 

for each key activity.)

The SOFA Safety Forum emerged as an unprecedented approach in the railroad industry for 

engaging key stakeholders in discussion with each other about the SOFA key findings prior to 

the 2010 SOFA Report release.

Table 6-4: SSF Themes by SOFA Key Finding

Finding Issues Barriers Actions

Job 

Briefing

• Term suggests one-way 

communication

• Unclear scope of briefing

• Appropriate or best 

approach in practice not 

implemented uniformly

• Productivity pressure, 

“Just get the work done.”

• Individualism; individual 

exception to safety risk, 

“Can’t happen to me.”

• Need two-way 

communication

• Identify and disseminate 

best practices

Mentoring • Lack of consensus on 

quality mentor criteria 

• Influx of new hires with 

<1.5 yrs.’ experience

• Small or one-person crews

• Not all experienced 

employees are candidates to 

be mentors

• Personality conflicts

• Lack of agreements 

between carrier and labor

• Training and education use 

rote instructional 

approaches

• Disinterest/unwillingness 

to mentor

• Experiential learning 

approaches, such as OJT

• Positive remedial 

learning

• Carrier-Labor 

Partnerships

• Program 

monitoring/feedback

Close 

Clearance

• Influx of new hires with 

<1.5 yrs.’ experience

• Unsafe equipment & 

working conditions

• Changing communications 

medium and strategies

• Too many rules; complex; 

non-standardization

• Individualism

• Lack of teamwork

• Practice from habits not 

education

• Lack of or unenforced 

agreements between 

carriers and clients

• Lack of communication 

systems

• Situational awareness

• Defensive switching

• Safety rules revision

• Safety site visits

• Safety hotlines

• Communication with 

clients

Industrial 

Hazards

• Influx of new hires with 

<1.5 yrs.’ experience

• Worker disempowered

• Unclear management buyin/support

• Inconsistent signage

• Lack of or unenforced 

agreements between 

carriers and clients

• Lack of communication 

systems

• Lack of education or 

training

• Safety site visits

• Safety hotlines

• Communication with 

clients, employees, and 

supervisors

• Initiate/Enforce industry

agreements

• Improve signage

Struck by 

Mainline 

Train

• Unsupervised industry

• Unclear communication 

strategies

• Punitive environment; 

employee blame

• Variable yard design and 

equipment

• Seasonal stressors on work 

duties and relationships

• Inadequate communication

• Depression in winter 

months

• Inadequate job briefing

• Situational awareness

• Defensive switching

• Share responsibility

• Active supervision

• Equipment improvements
71

6.6 Conclusion

As presented in this chapter, the purpose of the evaluation team and its work with the SWG 

focused on the utilization of SOFA report findings and implementing effective safety practices. 

Over time, the focus shifted progressively toward facilitating the ways the SWG can engage 

railroad industry stakeholders, prior to report release, to embrace SOFA findings, solicit their 

input, and generate action ideas for implementation in an ongoing effort to reach the goal of Zero 

Fatalities.

An overarching engagement strategy revealed itself through the delivery of the SSF: the power 

of presenting the preliminary SOFA findings to key stakeholder groups and including time for 

interactive discussion. (See Appendix K for a list of the outreach and initial implementation 

efforts by the SWG.) The unique event provided a first start, but the momentum must be 

sustained.

Moreover, in reflection of the SSF reactions and stakeholder discussions, the SWG continues to 

serve a significant role to the railroad industry through its analysis of FEs and dissemination of 

findings. The evaluation team asserts that the SWG can fill an even greater, more instrumental 

role in implementing its findings across the railroad industry by reviewing in an ongoing, 

continuous manner: (a) switching fatality cases, and (b) safety program implementation efforts. 

Following a clearinghouse model, the SWG would operate as a think-tank and could review

successful aspects of safety programs and disseminate them to the railroad industry as “effective 

practices” for implementation in the railroad industry. Ultimately, the ongoing review meetings 

of the SWG will promote greater utilization of SOFA findings and promote a railroad safety 

culture to reach the goal of Zero Fatalities.
72

7 ADDITIONAL SUGGESTED ACTIONS

7.1 Introduction

In Chapter 3, Switching Fatalities – Understanding and Prevention - the SOFA Working Group 

(SWG) suggested remedies and developed advisory statements for specific situations that are 

encountered in switching operations. The remedies and advisory statements in Chapter 3 

addressed five specific areas: job briefings, mentoring, close clearances, industrial hazards, 

struck by main line trains. This chapter covers suggested actions that either apply to more than 

one of the areas covered in Chapter 3 or improvements the SWG should make to its own role and 

approach.

7.2 Empowerment and Discipline

Safe practices in switching operations are the responsibility of all railroad industry employees.

Employees must be able to make decisions on safe actions and be allowed to cease work in the 

interest of safety. As expressed in many of the railroad’s empowerment statements, when 

performing safe actions employees should be free from reprisal by discipline, discrimination, or

harassment when executing those safe actions. When using discretion to choose safe actions, the 

employee should use that discretion appropriately. An empowered work environment allows the 

railroad industry to progress toward attaining the SOFA goal of Zero Fatalities.

7.3 FRA Fatality Investigation Process and Data Collection

We support FRA efforts to enhance the investigative process through an objective means to 

identify potential operational, organizational, and behavioral issues. In the SOFA 1999 report at 

section 5.1.3 the SWG committed among other things to “seek new lessons learned.” To that end 

we ask FRA to extend the process to include compiling data on issues, such as inappropriate 

pressure from co-workers, managers, or others that may have influenced behaviors that could 

lead to the occurrence of a fatality.

7.4 SWG Improvements

7.4.1 Transition the SWG From “Analysis” to “Analysis and Implementation”

Past SOFA tasking letters35

7.4.2 Conduct Annual SWG Meetings

called for a task force (later named the SWG) to conduct an analysis 

of switching fatalities. The SWG accomplished the analytical duties called for in these tasking 

letters with the October 1999 SOFA Report, the 2004 SOFA Update, and this report. The role of 

the SWG in promoting implementation is not clear in the tasking letters. The Group is not fully 

satisfied with the effect of the first two reports in terms of implementation and reduction in 

switching fatalities. To make this and future reports more successful, the SWG needs to expand 

its role further in the implementation phase. Each stakeholder organization has ideas concerning 

implementation. SWG duties should not end upon issuance of this report, and continued 

stakeholder support throughout the implementation phase is essential.

For this report, the SWG has met from January 2009 to December 2010. The frequency of 

meetings during this period (about once every month) made substantial demands on the members 

and their sponsoring organizations. The SWG recommends meeting three to four times a year to 

review current cases if needed, to monitor and identify trends, and to track the progress of 

 35 See Appendix B.
73

railroad industry implementation efforts. Reports and updates may not be issued every year.

Instead, they would be issued if necessary in response to any emerging trends that demand 

action. The benefits of this approach are:

• Case review is done while information is still fresh and those familiar with the cases may

be reached to provide clarification.

• SWG can spot trends while they are emerging and take appropriate action in informing 

the railroad industry.

• SWG can monitor railroad industry best practices and implementation of ideas. Deepen 

the SWG involvement in these areas as needed.

• Case review workload is no longer condensed, but is spread over a longer time period.

SWG members are no longer tied to an intense two-year schedule when it is time to 

produce an updated SOFA report.

• The SOFA effort remains dynamic and has a presence in the railroad industry.

• Reduces the blanket turnover of members and enhances the transfer of knowledge to new 

members of the SOFA process.

7.4.3 Improve the SOFA Database

The SOFA database includes over 200 data elements36. While most of these data elements were 

useful during analysis and deliberations, some were never used37. The SWG should continue its 

improvement of its data elements; scrub the data elements to maintain integrity, and consider 

removing elements which have not proven useful. The SWG also should look for opportunities 

to add new data elements as changes in railroad industry practice emerge and fatality 

investigations continue to improve38

During the SSF Job Briefing breakout session there was a discussion about expanding the criteria 

for SOFA 5. The proposed expansion would include cases where an action or inaction by an 

inexperienced employee may have contributed to the fatality of another employee. The SWG 

responded by reviewing all case data for employee experience and found many older cases did 

not contain data on the experience level of the surviving crew members

.

39. In cases where 

experience data was present, the SWG often could not determine the role of the inexperienced 

crew member. After examining all cases, the SWG found only one clear instance where the 

action of an inexperienced employee may have contributed to the fatality of another employee.

This case, for the purposes of our study, has not been included in the count of SOFA 5 cases. The 

SWG will consider this issue again during its next series of case reviews. 

 36 Section 2.8 provides background on the SOFA database and its important role in the SOFA process. 37 Many of these data elements were unused because the data was not available in the great majority of the cases 

reviewed.

38 A data element to track cases with Remote Controlled Locomotives is an example of a data element which the 

SWG recently added in response to a change in industry practice.

39 Following the 1999 SOFA Report (76 older cases) the FRA improved the detail and consistency of their 

investigation process.
DRAFT 4/8/2011 1 FOR SWG USE ONLY

Table of Contents

SOFA 1: Adjusting knuckles, adjusting knuckles, or installing EOT . . . . . . . . . . . . . . . . . . 

. 

2

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

. 

5

SOFA 3: Lack of or inadequate job briefing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

.

7

SOFA 4: Move controlled by a combination of hand and radio signals or specific distances 

were not given . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. 11

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

. 

15

Special Switching Hazard: Close Clearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

.

21

Special Switching Hazard: Derailment 27

Special Switching Hazard: Drugs and Alcohol 30

Special Switching Hazard: Electronic Device (Cell phone, MP3 player) 31

Special Switching Hazard: Employee Tripping, Slipping, or Falling 32

Special Switching Hazard: Environment 36

Special Switching Hazard: Equipment 37

Special Switching Hazard: Failure to Confirm Route of Movement 39

Special Switching Hazard: Free-Rolling Cars 41

Special Switching Hazard: Industrial Hazard 44

Special Switching Hazard: Miscellaneous 49

Special Switching Hazard: Struck by Mainline Train 52

Special Switching Hazard: Struck or Struck by Motor Vehicle 56

Special Switching Hazard: Unexpected Movement of Railcars 58

Special Switching Hazard: Unsecured Cars 60

Fatalities During Second Hour of Duty 63

Fatalities During High Risk Holiday Periods TBD

Fatalities In Cold Weather States During Winter TBD

Appendix A: SOFA Cases 1992 - 2009
DRAFT 4/8/2011 2 FOR SWG USE ONLY

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

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

Crew was in the process of coupling cars together in a class track. Standing equipment was not 

properly secured before conductor fouled the track to adjust couplers and the equipment rolled back 

in and coupled him up.

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

Crew switching in class yard, brakeman attempted to cross between equipment separated by an 

insufficient distance, and engineer moved locomotive in the wrong direction, coupling him up.

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

Crew coupling up cars in an industry track, brakeman attempted to couple air between cars when 

unexpected movement of railcars occurred, resulting in his fatal injury.

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

Two crews working in the same yard from opposite ends, one crew dropped ten free rolling cars in 

on top of the cut where the other crew’s foreman was installing the E.O.T. at the opposite end. Cars 

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

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

Switch crew was pulling a cut of cars out of an industry. Brakeman stepped in track gauge to open 

knuckle on the rear car at the same time crew shoved back to kick two cars that ran over the brakeman.

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

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

mis-aligned coupler on the fifteenth car after the cut was stretched. Switch foreman was facing the 

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

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

Three-person crew was switching in class yard, coupling between sixth and seventh car failed to 

couple. Conductor stopped locomotive and went between the cars to straighten the drawbar, and 

twenty-three cars rolled in behind him and coupled him up.
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SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

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

Three-person crew was switching in class yard, locomotive failed to couple to cut of seven standing 

cars. Yard foreman used hand signals to separate the locomotive by twenty feet. While adjusting the 

locomotive drawbar, the seven cars rolled in and coupled him up.

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

Crew was switching in class yard. Helper was attempting to adjust the drawbar in order to couple to 

three cars about forty feet away that had not coupled the first time. While adjusting the drawbar, the 

helper did not notice the three free-rolling cars coming back in on him and the cars coupled him up.

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

Crew was working in one track in class yard with helper controlling engine moves, conductor was 

adjusting coupler when three free rolling cars struck him from behind and coupled him up.

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

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

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

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

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

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

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

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

move was within two car lengths of a coupling, informed the conductor, and opened it. The 

conductor was crushed and killed between the leading car of the shove and the head car to be 

coupled to when the shove move unintentionally accelerated just prior to coupling.

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

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

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

the cars via radio, and the engineer stopped one half-car lengths after the last radio transmission of 

one-half cars to go. Subsequently, the engineer discovered that the conductor had stepped in 

between the cars and had been coupled up. 
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SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

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

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

adjust the coupler or drawbar.

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

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

moving equipment to open a knuckle while walking backwards.

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

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

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

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

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

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

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

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

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

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

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

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

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

conversation among the crew, yard foreman, utility employee and the yardmaster. The yard foreman

jumped on a ATV, rode it to the cut point, separated the train; and, when the cut not attached to the 

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

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

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

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

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

between the cars he had been trying to couple together. 
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SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

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

A conductor while engaged in switching operations attempted to uncouple freight cars from the 

locomotive, and was caught between the locomotive and these cars. The cars had not had their 

brakes secured as operating rules dictated they should. The conductor was killed.

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

A lone remote contol operator was working in a yard track coupling cars together to pull to place on 

a departure track. All cars had not coupled properly when switched into the track, and one car had 

the knuckle missing on the end of the car. The operator replaced the knuckle, then began movement 

to couple the track. Shortly after beginning the move to couple, the operator made a radio 

transmission for help when crushed between equipment because drawbars by-passed.

SOFA 2: Struck by equipment other than their own on yard or industry 

track.

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

The road job’s brakeman was trying to help the switch crew make up his train. The brakeman was in

between cars on an active track being used by the switch crew and was killed when the cars he was

between moved upon being struck by a cut of free rolling cars. 

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

Upon detraining, brakeman was struck and killed by another railroad’s yard job working in the same 

small yard. Members of both crews saw each other but the brakeman apparently did not see the short

line crews shove move.

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

Conductor riding side of two cars to be kicked, he moves to the opposite side of car to work hand 

brake and is immediately struck by locomotives standing on adjacent track creating a no-clearance 

condition. Conductor was not aware that the locomotives had arrived at that location since he had last 

been there.

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

The brakeman trainee was on the caboose to direct the shove move of the three engines, three cars 

and a caboose toward Track 1 in the yard. The shove move continued although the only radio 

transmission after getting the move started was “the derail is off.” The movement, which reached 

approximately 19 mph, struck standing equipment after diverging through two mis-aligned switches 

and killed the brakeman trainee.
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SOFA 2: Struck by equipment other than their own on yard or industry 

track.

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

Two crews working in the same yard from opposite ends, one crew dropped ten free rolling cars in 

on top of the cut where the other crew’s foreman was installing the E.O.T. at the opposite end. Cars 

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

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

Conductor was struck and killed by a shove move on the track adjacent to where he was working. 

Communication about the move on that adjacent track had been conveyed to the conductor via the 

“bleeder,” a utility type employee.

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

Two yard jobs working on adjacent tracks. The conductor of one is studying his switch list as the 

other job is shoving into the adjacent track. Conductor is struck and killed by the lead car of the 

adjacent track shove move.

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

Conductor and switchman making hoses on track 12, last transmission by conductor is “I think I got 

all the hoses after that next one....” Conductor later found to have been struck and killed by a free 

rolling car on the adjacent track.

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

Two yard engines working on adjacent tracks. One left a car fouling a clear track being used by the 

other engine. The foreman directing the shove move of the lite locomotives was crushed when his 

engine consist cornered the car fouling the adjacent track.

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

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

the adjacent yard track.

FE-2002-19 08-Aug-02 CWR Cleveland OH Switchman AGE: 53

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

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

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

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

was rolled between the car he was riding and the wide ladle car sitting on the adjacent track.
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SOFA 2: Struck by equipment other than their own on yard or industry 

track.

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

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

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

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

crew were waiting and the Shanty. The brakeman exited the Shanty and was struck by the shove 

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

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

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

A switch job was shoving cars into a yard track while another switch job was shoving cars on an 

adjacent track. The two tracks were separated by an 18 foot access road. The conductors 

discussed their movements with each other prior to the incident. The conductor of one switch job 

improperly position himself next to the adjacent track, and was struck by the other shoving movement.

SOFA 3: Lack of or inadequate job safety briefing.

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

The road job’s brakeman was trying to help the switch crew make up his train. The brakeman was in

between cars on an active track being used by the switch crew and was killed when the cars he was

between moved upon being struck by a cut of free rolling cars. 

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

Crew performing switching duties in class yard failed to have a clear understanding of movements 

being made. Results were that the rear brakeman was run over by moving equipment. There were no 

witnesses, but a hand brake was applied. It was thought that the brakeman had gone between the 

equipment on the ground to release the low hand brake.

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

Crew performing industry switching. Brakeman attempted to couple air hoses while conductor gave

engineer instructions to shove the movement. Resulting movement was unexpected to brakeman who

was fatally injured.

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

Trainmaster became involved with crew performing switching in class yard without knowledge of 

the conductor who was coupling air hoses on a cut of cars. Cars were shoved without his knowledge

while he was in the foul of the movement. Movement ran over conductor and killed him. 
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SOFA 3: Lack of or inadequate job safety briefing.

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

Change in operating procedure between two crews swapping equipment resulted in conductor being 

struck by unexpected movement while he was in the foul of the track. 

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

Crew switching in class yard failed to establish and maintain effective communications. Subsequent 

changes in switching line-up by the conductor resulted in trainman who was in the foul of Track 7 

being struck by unexpected movement of equipment.

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

Arbitrary change in switching operations by conductor resulted in him being unexpectedly struck and 

fatally injured by approaching cars while he was fouling the track.

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

Switch crew was pulling a cut of cars out of an industry. Brakeman stepped in track gauge to open 

knuckle on the rear car at the same time crew shoved back to kick two cars that ran over the brakeman.

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

A three person industry switching crew was in the process of switching cars back and forth over a 

private crossing equipped with an in-ground hand throw switch. The brakeman was at the switch 

and the conductor was going back and forth from one set of cars to another. The conductor shouted

to the brakeman that he wanted the next move down one track but the cars started down the other. 

The brakeman tried to warn the conductor who had his back to the move and then stopped the move 

but to late to save the conductor who was hit and run over by the leading car of the shove.

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

A three person yard switching crew was switching and the conductor was pulling pins while the 

brakeman was taking orders from him and working the yard tracks during a flat switching operation. 

The conductor cut off three cars that rolled into other cars on the track. The brakeman was run over

by these cars. 

FE-2000-30 15-Oct-00 UP Houston TX Fireman AGE: 47

Employees failed to discuss movement, resulting in employee falling from locomotive platform and 

being rolled between the locomotive and the elevated walkway.
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SOFA 3: Lack of or inadequate job safety briefing.

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

The engineer and conductor of a road train were told to stop and check their locomotives for flat 

spots. Once stopped, and without a job briefing the locomotive engineer left the lead unit and shortly 

thereafter, was struck and killed by a passing mainline train.

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

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

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

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

conversation among the crew, yard foreman, utility employee and the yardmaster. The yard foreman

jumped on a ATV, rode it to the cut point, separated the train; and, when the cut not attached to the 

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

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

A road conductor was riding the point of a 122-car shove down a track that was partially out of 

service. The out of service portion was marked by a red flag and derail. The crew was not able to 

stop the movement before the car being ridden by the conductor went over the derail, landed on its 

side and crushed the conductor to death.

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

A four person yard crew moving cars from the south end of the yard and lacing air hoses after each 

cut had the brakeman working alone at the north end of the yard. During the job briefing the crew 

agreed not to switch cars into track 102 where the brakeman was working. Brakeman was found 

between cars on track 103 at the time of the incident with leg severed below the groin, and died eight 

later.

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

An eastbound train stopped on the siding waiting the passage of a westbound train. The engineer saw

the headlight of the approaching train, and observed his conductor get up and exit on the live track 

side of the locomotive, contrary to rules. While attempting to cross to the other side of the track to 

conduct an inspection, the conductor paused in the middle of the track and the approaching train, 

sounding the horn and with headlight on bright, struck the conductor still standing on the track.
DRAFT 4/8/2011 10 FOR SWG USE ONLY

SOFA 3: Lack of or inadequate job safety briefing.

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

An eastbound train was stopped on the siding waiting for the passage of two westbound trains. The 

first train, approaching at a speed of 20 -23 mph, was observed by the engineer and heard the train 

sounding its whistle and bell. The conductor on the standing train got up and without a word, 

departed the locomotive's cab to conduct a roll-by inspection and stepped off the standing train 

locomotive on the live side between tracks. The approaching train struck the conductor, killing the 

conductor.

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

A remote control assignment was switching on the east end of the yard. While making a shove 

movement into a yard track with a helper riding on the leading end of a tank car, the movement 

struck 28 standing cars in the track causing the helper to fall from the tank car, which then ran over 

helper.

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

A three person crew shoving into an industry track found cars left foul of an adjacent track by 

industry employees. The conductor held a job briefing with the brakeman on the moves to be made, 

and the brakeman understond he would control the switching and car movements. After shoving the 

cars to make the coupling, the conductor told the brakeman the cars were coupled and he was in the 

clear. The brakeman attempted to uncouple from the cars, but failed. He then requested the engineer

make a second move to create slack between the cars so they could be uncoupled. The engineer 

complied and the conductor who was in the foul of track and equipment suffered fatal injuries.

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

A remote control operator controlling a shoving movement was riding the leading end of the two car 

move when he struck the side of another standing car. The standing car fouled the crossover switch

which the movement was lined to operate through, killing the operator.

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

After reaching their destination, a two person crew was instructed to secure their freight train at a 

location beyond the normal crew change point. The location was on double track on a bridge near a 

parking lot where a relief crew could reach the train. The conductor left the cab of the locomotive 

without job-briefing with the Engineer and without his hand-held radio. He crossed in front of the 

locomotive and walked eastward across the bridge between the two tracks. There was poor footing 

and almost no clearance between the two tracks. An eastbound approaching train, operating at 26 

mph, observed the conductor, sounded the whistle, turned the head lights to bright, and tried to stop. 

The eastbound train struck and killed the conductor who was walking in the foul. 
DRAFT 4/8/2011 11 FOR SWG USE ONLY

SOFA 3: Lack of or inadequate job safety briefing.

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

A three person crew, operating a local freight train, moved their locomotives to a make-up track. 

After a job briefing, the switchman proceeded to make sure the train was together and the air hoses 

were coupled. The switchman did not observe sixteen cars at the end of the train were not coupled. 

A few minutes later, he radioed he was going between to make an air hose. The Engineer said: “Set 

and centered.” A few minutes earlier, the Conductor was walking the head-end and found a gap. 

Without communicating with the Switchman, the Conductor instructed the Engineer to pull forward 

so that he could open knuckles and prepare for a reverse movement to a coupling. Apparently, when 

the train moved forward, the 16 cars at the rear of the train began to roll, just as the Switchman was 

reaching in to connect an air hose. The 16 free-rolling cars struck the standing portion of the train 

and killed the Switchman. 

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

A two person road freight train crew was operating on the main track westbound when the engineer 

exited the cab of the controling locomotive to got to the trailing locomotive. The conductor, a 

qualified locomotive engineer, took over operation of the locomotive and train. After several minutes 

when the engineer had not returned, the conductor stopped the train and went in search of the 

engineer and notified the dispatcher. A following westbound train found the engineer on a parallel 

road where he had fallen from the train. The engineer died as a result of injuries sustained in the fall.

SOFA 4: Move controlled by a combination of hand and radio signals or 

specific distances were not given.

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

A four-person crew (engineer, switch foreman, 2 switchman) had just shoved cars into track 11 and 

held onto one for track 9. The switch foreman got the switch for 9, noticed his front switchman 

standing near cars on track 11, and rode the locomotive onto the lead. After the 11th switch was 

lined for the lead, the switch foreman kicked the single car into track 9. The front switchman was 

struck and killed by the free rolling car.

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

This case involved the conductor riding a car into Track 8. The car derailed at the spiked switch and 

the conductor was subsequently killed. The conductor’s last radio transmission was “...we’re lined in

eight rail, three or four cars to a joint.” Movement stopped after car had derailed and side swiped 

adjacent car.
DRAFT 4/8/2011 12 FOR SWG USE ONLY

SOFA 4: Move controlled by a combination of hand and radio signals or 

specific distances were not given.

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

Brakeman had control of the move and told the engineer, by radio, to back up six cars to a coupling. 

The brakeman assumed that the conductor would “pick-up” the move when it came into his (the 

conductor’s) view. The movement continued until it struck sitting cars on the track which, when 

moved, killed the conductor who was in between them.

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

A three-person crew had arrived at the yard, pulled their train into a track, cut off the engines and 

were given permission to return to the other end of the yard via an adjacent clear track. The 

conductor remained on the end originally entered and the brakeman stayed with the engineer. The 

brakeman got what he thought was the proper switch, instructed the engineer by radio to back up 

and, apparently turned his back on the move. Before the brakeman had a chance to mount the 

returning locomotives, he was struck and killed by the movement that continued for 400 feet before 

stopping when the engineer noticed the brakeman between the gauge of the rail in front of the 

locomotives.

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

After the brakeman had tied the locomotives onto a cut of cars in the yard, the engineer received an 

instruction, via radio, from the brakeman to “shove to hold more cars.” The engineer began to shove 

and didn’t stop until he was on the other end of the track. The brakeman was run over by the shove 

move. There was no evidence of any other radio transmissions concerning the shove move.

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

Crew performing industry switching. Brakeman attempted to couple air hoses while conductor gave 

engineer instructions to shove the movement. Resulting movement was unexpected to brakeman who

was fatally injured.

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

Crew switching in class yard failed to establish and maintain effective communications. Subsequent 

changes in switching line-up by the conductor resulted in trainman who was in the foul of Track 7 

being struck by unexpected movement of equipment.

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

The brakeman trainee was on the caboose to direct the shove move of the three engines, three cars 

and a caboose toward Track 1 in the yard. The shove move continued although the only radio 

transmission after getting the move started was “the derail is off.” The movement, which reached 

approximately 19 mph, struck standing equipment after diverging through two mis-aligned switches 

and killed the brakeman trainee.
DRAFT 4/8/2011 13 FOR SWG USE ONLY

SOFA 4: Move controlled by a combination of hand and radio signals or 

specific distances were not given.

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

Arbitrary change in switching operations by conductor resulted in him being unexpectedly struck and 

fatally injured by approaching cars while he was fouling the track.

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

Conductor and engineer were moving toward engine house area with lite engines and using hand 

signals. The conductor stopped the movement to line a switch. The engineer while waiting heard and 

acted upon an unidentified radio transmission “come ahead 21.” The engineer initiated the shove 

movement and eventually, the conductor was struck from behind and killed.

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

Conductor began a move using radio communication to shove a cut of cars approximately twentyfive car lengths to a coupling. After the move had begun the engineer didn’t hear another radio 

transmission from his conductor. The shove move eventually collided with the cars that were to be 

coupled to. The conductor was crushed in the collision and it was later determined that the portable 

radio being used by the conductor may have lost enough of it’s charge to effect the transmission. 

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

Conductor was riding equipment while setting hand brakes. Move was being shoved; improper radio 

communication.

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

Shove movement was not properly controlled by radio communication and resulted in a collision with

a fallen tree which caused the derailment and death of the conductor. 

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

A three person industry switching crew was in the process of switching cars back and forth over a 

private crossing equipped with an in-ground hand throw switch. The brakeman was at the switch 

and the conductor was going back and forth from one set of cars to another. The conductor shouted

to the brakeman that he wanted the next move down one track but the cars started down the other. 

The brakeman tried to warn the conductor who had his back to the move and then stopped the move 

but to late to save the conductor who was hit and run over by the leading car of the shove.
DRAFT 4/8/2011 14 FOR SWG USE ONLY

SOFA 4: Move controlled by a combination of hand and radio signals or 

specific distances were not given.

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

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

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

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

move was within two car lengths of a coupling, informed the conductor, and opened it. The 

conductor was crushed and killed between the leading car of the shove and the head car to be 

coupled to when the shove move unintentionally accelerated just prior to coupling.

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

A two-person yard switching crew was in the process of moving their light locomotives to a track 

where it was to be stored for the night. The conductor was on the leading end of the unit and 

directing the move by radio communication. After instructing the engineer to stop, the conductor got

off the locomotive, lined two switches and told the engineer to back up. The engineer backed up 

until he placed the unit at the location where it is always left without further radio contact from his 

conductor. The conductor was struck and killed by the locomotive and found, by the engineer, 

under the locomotive’s fuel tanks.

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

While shoving one car into an industry site, and using radio communication, the switch foreman was 

run over by the leading wheel as the shove move continued until coupling was made.

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

While shoving lite engines back to train on mainline, employees failed to control the movement by 

radio, resulting in a collision with a standing train.

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

A two person conventional yard switching assignment was shoving a cut of cars into a track with the

conductor controlling the move by radio. Radio communicaton between the conductor and engineer 

ceased, the movement was stoped, and the conductor was found by the engineer beneath the equipment.
DRAFT 4/8/2011 15 FOR SWG USE ONLY

SOFA 4: Move controlled by a combination of hand and radio signals or 

specific distances were not given.

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

A three person train crew was performing switching operations at an industrial location. The 

brakeman controlling movements by radio, instructed the engineer to back up four cars to a coupling.

 The engineer, watching in the side mirror of the locomotive, noticed the cars moving down curved 

track instead of the straight track to the coupling. The switch target as seen in the mirror indicated 

the switch was lined for the spur track, not the straight track. The engineer saw someone walk in 

front of the movement and it was determined later to be the brakeman, who was struck and killed by 

the erroneous movement. Cellular telephone records indicated the brakeman had made or received 

several telephone calls, including a two-minute call during the time of the fatal shove over the 

misaligned switch. 

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

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

Industry switch crew, engineer and two flagmen, both flagmen rode the lower steps of the leading 

end of the lead locomotive. FE (flagman) was on left side, the other flagman on right side. After 2000

feet into this light engine movement the surviving flagman noticed the FE stopped talking and he 

crossed over to the FE’s side and saw FE lying next to the track behind movement. Investigation 

showed FE either slipped off the fireman’s side or tripped while dismounting or attempting to 

remount from the fireman’s side. FE had six months experience.

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

Road switcher R90371-26, was switching cars at Fulton Yard in Fulton, Kentucky. The conductor 

on the job had ridden shove movement into track seven and secured car and remained at that location 

while the remainder of the crew switched cars between track seven and track five. At 4:25 a.m., 

after free rolling the last car into track seven, and while coupling to cars on lead to shove clear of 

track six, the conductor called via the radio and stated he had been hurt. The conductor was found 

beneath the L-1 wheel of GATX 10818 in the gauge of track seven and later expired due to injuries 

sustained.

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

A three-person train crew was in the process of picking up 18 cars off a siding. The trainman had 

10 weeks of experience, forgot to remove the derail, and was killed when the leading car he was 

riding derailed on top of him. During the stop, the conductor remained in the cab of the lead 

locomotive with the engineer.
DRAFT 4/8/2011 16 FOR SWG USE ONLY

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

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

Trainmaster became involved with crew performing switching in class yard without knowledge of 

the conductor who was coupling air hoses on a cut of cars. Cars were shoved without his knowledge

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

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

Yard switch crew, engineer, conductor and brakeman, spotting paper mill. FE (brakeman) instructed 

by conductor to de-train and stay at road crossing while he spotted track. FE found in nearby wood 

chip auger/conveyer system after mill crew started up the system while crew searched for missing 

FE. Mill crew was instructed by conductor not to start equipment until FE was located. FE was not 

familiar with the dangers associated with this mill process. FE had 5 months experience.

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

The brakeman trainee was on the caboose to direct the shove move of the three engines, three cars 

and a caboose toward Track 1 in the yard. The shove move continued although the only radio 

transmission after getting the move started was “the derail is off.” The movement, which reached 

approximately 19 mph, struck standing equipment after diverging through two mis-aligned switches 

and killed the brakeman trainee.

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

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

mis-aligned coupler on the fifteenth car after the cut was stretched. Switch foreman was facing the 

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

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

Three-person crew was switching in class yard, coupling between sixth and seventh car failed to 

couple. Conductor stopped locomotive and went between the cars to straighten the drawbar, and 

twenty-three cars rolled in behind him and coupled him up.

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

Yard crew, engineer, conductor and switchman, switching at an industry. While crew was shoving 

two cars to a spot inside an industry building, FE (switchman) was rolled between lead box car and 

unloading platform. Platform or building was not marked with any type of ‘no-clearance’ or ‘close 

clearance’ signage. FE was last seen by conductor on the ground next to movement in a ‘cut-out’ 

space in the unloading platform. The conductor reported that there is enough room for a man to clear

the movement in this ‘cut-out’. After hearing a strange noise the conductor instructed engineer to 

stop the movement. FE was rolled for 21 feet between boxcar and platform. FE had one year of 

experience.
DRAFT 4/8/2011 17 FOR SWG USE ONLY

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

FE-1996-17 07-Jul-96 NS Sidney IN Conductor AGE: 29

Road crew, engineer and conductor, while stopped on siding track to meet an opposing train, FE 

(conductor) detrained to perform a roll-by inspection of other train. FE stepped off his train shortly 

before opposing trains arrival then stood in that trains track while trying to adjust his portable radio. 

Opposing train struck FE at this point. FE had one year of experience.

FE-1996-22 03-Sep-96 DGN Dallas TX Brakeman AGE: 43

Yard switch crew, engineer, conductor and brakeman, while switching at an industry on a downhill 

grade experienced an unwanted run away car. While FE (brakeman) was in position on a car and 

setting a hand brake, the car started to roll away from the crew. FE continued to try to apply hand 

brake in an effort to stop the car. When discovering that the car was rolling away, the conductor 

attempted to slow and stop it by putting wood blocks under the wheels. The car accelerate to 30 to 

35 mph. FE did not detrain before car collided with seven other cars at that speed. FE had three weeks 

experience.

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

Three-person crew was switching in class yard, locomotive failed to couple to cut of seven standing 

cars. Yard foreman used hand signals to separate the locomotive by twenty feet. While adjusting the 

locomotive drawbar, the seven cars rolled in and coupled him up.

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

Yard switch crew, engineer, switch foreman and switchman, were shoving a cut 41 cars up a grade 

to a stop. While this was taking place the ground crew boarded the first two cars so they could apply

the hand brakes. FE (switchman) fell off the first car while attempting this. This car was found to 

have a brake platform with a decreasing width. Under the hand brake this platform was found to be 2

inches under the required width over a length of about 30 inches. FE had 10 months experience.

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

Two yard engines working on adjacent tracks. One left a car fouling a clear track being used by the 

other engine. The foreman directing the shove move of the lite locomotives was crushed when his 

engine consist cornered the car fouling the adjacent track.

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

A three person local switching crew was shoving a loaded covered hopper down an industrial lead. 

The conductor was riding on one side of the car and the brakeman was riding the other. As the car 

was shoved over a private crossing, the accumulation of ice and snow lifted the car off the rails and 

it tipped over and onto the conductor who was killed as a result of the derailment.
DRAFT 4/8/2011 18 FOR SWG USE ONLY

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

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

A conductor with one year of service was riding in the stairwell of the leading locomotive. He was 

directing the move by radio when he realized to late that the move would not clear the standing 

equipment. He was crushed between the handrail of his locomotive and the standing locomotive.

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

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

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

the cars via radio, and the engineer stopped one half-car lengths after the last radio transmission of 

one-half cars to go. Subsequently, the engineer discovered that the conductor had stepped in 

between the cars and had been coupled up. 

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

Conductor with 14-months service was struck and killed by passing mainline train while attempting to

board locomotive at crew-change point.

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

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

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

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

conversation among the crew, yard foreman, utility employee and the yardmaster. The yard foreman

jumped on a ATV, rode it to the cut point, separated the train; and, when the cut not attached to the 

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

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

A two-person train crew was in the process of setting off and picking up cars in a small yard. The 

conductor, who had 8 weeks of experience, was killed when the leading car of the shove struck him 

as he stepped into its path.

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

A two person remote control crew switching in the yard when an empty tank car passed through a 

switch and derailed, this caused the car to shake and bounce violently. The conductor/switchman 

lost his hold on the car and fell off between the rails, and was run over and killed.
DRAFT 4/8/2011 19 FOR SWG USE ONLY

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

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

A road train pulling around the connection track derailed nine cars while pulling. The student 

brakeman located to the side of the track where the cars derailed was crushed when a car derailed 

and fell over. The student brakeman did not follow instructions given him at a job briefing given by 

the train conductor shortly before the incident occurred.

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

An eastbound train stopped on the siding waiting the passage of a westbound train. The engineer saw

the headlight of the approaching train, and observed his conductor get up and exit on the live track 

side of the locomotive, contrary to rules. While attempting to cross to the other side of the track to 

conduct an inspection, the conductor paused in the middle of the track and the approaching train, 

sounding the horn and with headlight on bright, struck the conductor still standing on the track.

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

A remote control assignment was switching on the east end of the yard. While making a shove 

movement into a yard track with a helper riding on the leading end of a tank car, the movement 

struck 28 standing cars in the track causing the helper to fall from the tank car, which then ran over the 

helper.

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

A 24-year-old conductor with 3 months experience died of injuries he sustained when the car he was 

riding on derailed and he was crushed between the car and a steel I-beam.

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

A three person train crew was switching cars on industrial track when the train passed through a 

misaligned crossover switch and colided with a car out to foul on an adjacent track. The trainman 

was crushed on impact against this car.

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

A two person switching crew conducted a job briefing associated with switching operations at an 

industry plant. The crew coupled 10 empty covered hopper cars and commenced the move with the 

conductor riding the B- end of a covered hopper. The car being shoved struck a drainage grate lying 

in the gage of the track and swerved off the track onto a concrete apron of the same height as the 

track. The conductor was trapped between the car and the conrete wall and dragged along the wall 

for a distance of 16 feet, killing him. Clearance between the wall and car was 27 inches; The US 

Deparment of Labor requires a minimum clearance of 30 inches unless the lesser clearance is 

conspicuously marked, which it wasn't.
DRAFT 4/8/2011 20 FOR SWG USE ONLY

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

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

A three person switch crew held a job briefing with the intent to deliver 125 car loads of coal onto 

five (5) industry tracks. Only the engineer was familiar with the industry plant and its tracks. The 

engineer offered to operate the locomotive into the plant to allow the rest of the crew to become more

familiar with the work area; the other crew members declined. The track passes under an overhead 

walkway with only 5 1/2 inch clearance between the part of the car on which the brakeman was 

riding, and a support beam of the walkway. The brakeman failed to take heed of this situation and 

was fatally injured when he was crushed between the car and the support member.

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

A two person crew was in the process of making up a locomotive consist using two adjacent tracks. 

After setting over one of the locomotives, the conductor rode the leading end of the two locomotives 

into the adjacent track. When his had signals went out of sight, the movement was stopped and the 

engineer went back to discover the conductor crushed between the locomotive they set out and the 

locomotive he was riding.

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

A 52 year old yard foreman with 6 months service was crushed and killed while riding the leading end

of a five locomotive consist when it passed through a mis-aligned crossover switch and collided with

a standing train on an adjacent track.

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

A three person train crew operated a freight train consisting of three locomotives and 97 loaded coal 

hoppers. The conductor had one year of experience – interrupted by a four month furlough – and a 

student engineer were a part of the train crew. The train crew began shoving to spot the coal 

hoppers into a generating plant. The conductor had not work in this plant previously but was told 

plant employees would help if needed. The conductor rode the shove movement giving car counts 

via radio. The last radio transmission from the conductor to the student engineer, who was operating

the train, was “give me all you’ve got, then “stop.” The lead two cars had plowed through a large 

pile of coal knocking the conductor from the car, crushing the conductor. 
DRAFT 4/8/2011 21 FOR SWG USE ONLY

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

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

A three person crew, operating a local freight train, moved their locomotives to a make-up track. 

After a job briefing, the switchman proceeded to make sure the train was together and the air hoses 

were coupled. The switchman did not observe sixteen cars at the end of the train were not coupled. 

A few minutes later, he radioed he was going between to make an air hose. The Engineer said: “Set 

and centered.” A few minutes earlier, the Conductor was walking the head-end and found a gap. 

Without communicating with the Switchman, the Conductor instructed the Engineer to pull forward 

so that he could open knuckles and prepare for a reverse movement to a coupling. Apparently, when 

the train moved forward, the 16 cars at the rear of the train began to roll, just as the Switchman was 

reaching in to connect an air hose. The 16 free-rolling cars struck the standing portion of the train 

and killed the Switchman. 

Special Switching Hazard: Close Clearance.

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

A three person industrial switching crew was shoving three cars down a track. The conductor was 

on the ground, ahead of the move and the brakeman was riding the side of the leading end of the 

leading car. A bush created a clearance issue and the brakeman stepped around the side of the 

leading car to the end of the car just as it began to derail. The brakeman was killed when he fell from the 

derailing car.

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

Conductor riding side of two cars to be kicked, he moves to the opposite side of car to work hand 

brake and is immediately struck by locomotives standing on adjacent track creating a no-clearance 

condition. Conductor was not aware that the locomotives had arrived at that location since he had last

been there.

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

A three person switching crew was in the process of switching out the car repair shop. The foreman

had taken a position on the trailing end of the third leading car as the move was being shoved into a 

track having a close clearance condition that involved a protective grate that covered a winch. The 

foreman was knocked off the car by the covering, fell in front of the leading wheels of the forth 

leading car, and was later pronounced dead at the hospital.
DRAFT 4/8/2011 22 FOR SWG USE ONLY

Special Switching Hazard: Close Clearance.

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

A three-person crew was called to switch an industry that all were very familiar with. During the 

switching moves, the brakeman was inside an area with no clearances between the cars and the hand 

railings installed on the walls. He was making coupling and, according to the conductor and engineer,

upon completion of that work, ordered the engineer to haul out of the building where the conductor 

would take over the next move to be performed. Subsequently, a plant employee observed the 

brakeman slumped beside the track, rushed to assistance, call 911 and notified the conductor that his 

man was down. The brakeman died later on at the hospital of crushing wounds incurred when he 

was rolled between the cars being pulled out and the railing.

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

A three-person crew (engineer, conductor & conductor trainee) was called to operate a local freight 

train. During a switching operation at a yard, the conductor was riding nine cars down a clear track 

and directing the shove move by radio. When the engineer did not hear any more radio transmissions 

from the conductor, he stopped the move and found the conductor dead and lying beside the track he

had been shoving down. Post accident investigation revealed that he had been struck by a truck 

trailer door positioned on a flat car standing on an adjacent track and that had been left open and 

swinging freely. The investigation revealed that a vandal had broken into the trailer and stolen material 

from it.

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

Yard crew, engineer, conductor and switchman, switching at an industry. While crew was shoving 

two cars to a spot inside an industry building, FE (switchman) was rolled between lead box car and 

unloading platform. Platform or building was not marked with any type of ‘no-clearance’ or ‘close 

clearance’ signage. FE was last seen by conductor on the ground next to movement in a ‘cut-out’ 

space in the unloading platform. The conductor reported that there is enough room for a man to clear

the movement in this ‘cut-out’. After hearing a strange noise the conductor instructed engineer to 

stop the movement. FE was rolled for 21 feet between boxcar and platform. FE had one year of 

experience.

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

Conductor and switchman making hoses on track 12, last transmission by conductor is “I think I got 

all the hoses after that next one....” Conductor later found to have been struck and killed by a free 

rolling car on the adjacent track.
DRAFT 4/8/2011 23 FOR SWG USE ONLY

Special Switching Hazard: Close Clearance.

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

A three person local switching crew (conductor, engineer and utility employee) had just begun to pull 

five cars out of an industrial loading dock while the conductor and the utility employee began to walk 

toward the door providing egress out of the dock area. Suddenly, according to the conductor, the 

utility employee allegedly tripped on some material on the dock, grabbed the side of the outgoing cut 

of cars and was pulled between the car he was holding onto and the handrail structure that 

accompanied the stairs leading from the platform to the door. He died two weeks later.

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

A three person road switching crew was in the process of spotting loaded coal cars at a unloading 

facility that was equipped with a “shaker” that helped empty each car. The shaker’s position causes 

a close clearance condition. The conductor was riding one side of the leading coal car and the 

brakeman was riding the other. Although having a clear view of the fouling equipment, the brakeman

did not get off the car as the conductor had expected and was crushed between it and the fouling 

shaker equipment. 

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

A three person local switching crew was in the process of setting cars into a track within an 

industry. The switchman was riding the side ladder of the leading end of the leading car as it went 

into the building. The doorway would not clear a man riding on the side of the car and the trainman 

was killed as he was compressed between it and the car he was riding.

FE-2000-30 15-Oct-00 UP Houston TX Fireman AGE: 47

Employees failed to discuss movement, resulting in employee falling from locomotive platform and 

being rolled between the locomotive and the elevated walkway.

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

A three-person, local freight train crew was switching a plant and had 2 engines 6 cars and a caboose

when they moved over a small bridge and coupled to 5 standing cars in the storage track. The 

conductor made the coupling and told the engineer to pull the cars out of the track. The conductor 

got on the side of the trailing end of the second last car in the cut and was knocked off the car by a 

metal pole adjacent to the storage track. He fell between the car he was riding and the last car in the 

cut being pulled. He died when the lead wheels of the last car rolled over him.
DRAFT 4/8/2011 24 FOR SWG USE ONLY

Special Switching Hazard: Close Clearance.

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

A conductor, engineer and conductor in training had been transported to an unattended train standing 

on a siding a portion of which was in a tunnel adjacent to the main track. After storing their 

equipment, the conductor and the conductor in training left the locomotive to release hand brakes on 

the train. The conductor was killed when she failed to step in between two boxcars of her train as the

conductor in training had done and was subsequently struck by a passing mainline train. 

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

A locomotive engineer had been dropped off at the head end of his train while the conductor was 

taken to the rear to check on the REM. After crossing over the ATK corridor mainline tracks, and 

beginning to board his locomotive, the engineer was dragged off the stairs of the locomotive and 

killed by a passing 110 MPH passenger train. 

FE-2002-19 08-Aug-02 CWR Cleveland OH Switchman AGE: 53

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

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

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

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

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

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

A 24-year-old conductor with 3 months experience died of injuries he sustained when the car he was 

riding on derailed and he was crushed between the car and a steel I-beam.

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

A two person switching crew conducted a job briefing associated with switching operations at an 

industry plant. The crew coupled 10 empty covered hopper cars and commenced the move with the 

conductor riding the B- end of a covered hopper. The car being shoved struck a drainage grate lying 

in the gage of the track and swerved off the track onto a concrete apron of the same height as the 

track. The conductor was trapped between the car and the conrete wall and dragged along the wall 

for a distance of 16 feet, killing him. Clearance between the wall and car was 27 inches; The US 

Deparment of Labor requires a minimum clearance of 30 inches unless the lesser clearance is 

conspicuously marked, which it wasn't.
DRAFT 4/8/2011 25 FOR SWG USE ONLY

Special Switching Hazard: Close Clearance.

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

A three person crew prepared to spot cars at a loading dock with the brakeman riding on the cars 

being moved. Clearance at the loading dock is restricted, though no notice of this condition was 

posted. As the engineer proceeded with the shove, the brakeman noticed the conductor was pinned 

between the dock and the car body.

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

A three person switch crew held a job briefing with the intent to deliver 125 car loads of coal onto 

five (5) industry tracks. Only the engineer was familiar with the industry plant and its tracks. The 

engineer offered to operate the locomotive into the plant to allow the rest of the crew to become more

familiar with the work area; the other crew members declined. The track passes under an overhead 

walkway with only 5 1/2 inch clearance between the part of the car on which the brakeman was 

riding, and a support beam of the walkway. The brakeman failed to take heed of this situation and 

was fatally injured when he was crushed between the car and the support member.

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

A two person crew was in the process of making up a locomotive consist using two adjacent tracks. 

After setting over one of the locomotives, the conductor rode the leading end of the two locomotives 

into the adjacent track. When his had signals went out of sight, the movement was stopped and the 

engineer went back to discover the conductor crushed between the locomotive they set out and the 

locomotive he was riding.

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

A three person switching crew working with a student switchman began switching following a safety

briefing. Two rail cars kicked toward a track stalled foul of the clearance point on the adjacent 

track. The next car switched was rolling free when the footboard yardmaster/switch foreman and 

student switchman saw that the cars were fouling the clearance point. The footboard 

yardmaster/switch foreman in an attempt to board and stop the free rolling car became trapped 

between the sides of the cars and carried for a distance between the cars.

FE-2008-06 05-Mar-08 WSO Random Lake WI Freight Conductor AGE: 55

A three-person crew (engineer, conductor, and student conductor) arrived at an industrial spot where

they were required to spot 2 loads. This industry had not been spotted for about a month and three 

inches of accumulated snow was covering packed ice on the spur track. The conductor rode the 

leading end of the first car adjacent to the standing train on the main track and the student conductor 

rode the opposite side of the same car, controlling the movement by radio. Due to the build-up of 

packed ice and mud in the flange-way the car derailed into the side of cars left standing on the main 

track, and the conductor was crushed between the cars.
DRAFT 4/8/2011 26 FOR SWG USE ONLY

Special Switching Hazard: Close Clearance.

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

A three person train crew operated a freight train consisting of three locomotives and 97 loaded coal 

hoppers. The conductor had one year of experience – interrupted by a four month furlough – and a 

student engineer were a part of the train crew. The train crew began shoving to spot the coal 

hoppers into a generating plant. The conductor had not work in this plant previously but was told 

plant employees would help if needed. The conductor rode the shove movement giving car counts 

via radio. The last radio transmission from the conductor to the student engineer, who was operating

the train, was “give me all you’ve got, then “stop.” The lead two cars had plowed through a large 

pile of coal knocking the conductor from the car, crushing the conductor. 

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

The conductor of a two person local freight crew was riding the leading end on the side of a tank car

during an industry switching job. The conductor was crushed and killed when the leading car 

derailed and struck a stack of bundled wood railroad ties adjacent to the track. The car derailed on 

compacted aggregate which had been placed as an adhoc crossing on the industry track. The shove 

movement was proceeding at 7 mph on track with a 5 mph maximum speed.

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

After reaching their destination, a two person crew was instructed to secure their freight train at a 

location beyond the normal crew change point. The location was on double track on a bridge near a 

parking lot where a relief crew could reach the train. The conductor left the cab of the locomotive 

without job-briefing with the Engineer and without his hand-held radio. He crossed in front of the 

locomotive and walked eastward across the bridge between the two tracks. There was poor footing 

and almost no clearance between the two tracks. An eastbound approaching train, operating at 26 

mph, observed the conductor, sounded the whistle, turned the head lights to bright, and tried to stop. 

The eastbound train struck and killed the conductor who was walking in the foul. 

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

A four person yard switching crew was pulling cars up to make a shoving movement into a yard 

track, while a road train was approaching in the same direction on the main track adjacent to the 

switching lead. The conductor riding in the second locomotive of the yard switcher exited the cab 

and got off on the live side next to the main track, fouling the main track, and was struck by the passing 

road train.
DRAFT 4/8/2011 27 FOR SWG USE ONLY

Special Switching Hazard: Close Clearance.

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

A two person road train with the conductor riding the end car made a shoving movement into the 

siding to leave cars on the siding. The movement was controlled by radio communications from the 

conductor during the shove. During the shove movement the conductor was knocked off when the 

conductor impacted a tie bundle closely positioned next to the rail. The impact caused the conductor 

to be knocked off the equipment and killed.

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

A two person crew was shoving cars into spot at an industry with the conductor contolling the 

movement via radio communications. The conductor gave car counts from 12 down to 3 during the 

shove, and shortly after that transmission the engineer stopped the movement when he heard an "OH"

transmission. The conductor was found deceased on the leading end of the lead car on the platform,

pinned against a car of scrap metal.

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

A two-person RCL crew shoved five empty cars into a snow-covered industry track. Ice build-up 

on the track caused the lead car of the movement to derail. The RCL operator, riding the lead car and

contolling the move, was crushed against the side of an industry building and fatally injured.

Special Switching Hazard: Derailment.

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

This case involved the conductor riding a car into Track 8. The car derailed at the spiked switch and 

the conductor was subsequently killed. The conductor’s last radio transmission was “...we’re lined in

eight rail, three or four cars to a joint.” Movement stopped after car had derailed and side swiped 

adjacent car.

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

A three person industrial switching crew was shoving three cars down a track. The conductor was 

on the ground, ahead of the move and the brakeman was riding the side of the leading end of the 

leading car. A bush created a clearance issue and the brakeman stepped around the side of the 

leading car to the end of the car just as it began to derail. The brakeman was killed when he fell from the 

derailing car.
DRAFT 4/8/2011 28 FOR SWG USE ONLY

Special Switching Hazard: Derailment.

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

A three-person train crew was in the process of picking up 18 cars off a siding. The trainman had 

10 weeks of experience, forgot to remove the derail, and was killed when the leading car he was 

riding derailed on top of him. During the stop, the conductor remained in the cab of the lead 

locomotive with the engineer.

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

A three-person crew reported for duty and later was in the process of shoving cars down a track 

with the switch foreman riding the point. At the same time, another yard switching job was pulling 

cars in the opposite direction on an adjacent track and derailed. The foreman immediately told the 

other crew that they were on the ground and then told his engineer to stop the shove he was riding. 

The foreman was found crushed between the car he was riding and the car that derailed on the adjacent 

track.

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

Shove movement was not properly controlled by radio communication and resulted in a collision with

a fallen tree which caused the derailment and death of the conductor. 

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

A three person local switching crew was shoving a loaded covered hopper down an industrial lead. 

The conductor was riding on one side of the car and the brakeman was riding the other. As the car 

was shoved over a private crossing, the accumulation of ice and snow lifted the car off the rails and 

it tipped over and onto the conductor who was killed as a result of the derailment.

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

The three-person crew had just finished kicking a flat car into a clear track and the conductor was 

about to mount the leading end of a cut of cars to be kicked into another track further down the lead. 

As the conductor issued instructions to the engineer to begin the move, and to the crew, the flat car 

had not cleared the fouling point to the lead. The shove move rode up onto the flat car derailing the 

car the conductor was riding on which crushed him to death.

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

A road conductor was riding the point of a 122-car shove down a track that was partially out of 

service. The out of service portion was marked by a red flag and derail. The crew was not able to 

stop the movement before the car being ridden by the conductor went over the derail, landed on its 

side and crushed the conductor to death.
DRAFT 4/8/2011 29 FOR SWG USE ONLY

Special Switching Hazard: Derailment.

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

A two person remote control crew switching in the yard when an empty tank car passed through a 

switch and derailed, this caused the car to shake and bounce violently. The conductor/switchman 

lost his hold on the car and fell off between the rails, and was run over and killed.

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

A road train pulling around the connection track derailed nine cars while pulling. The student 

brakeman located to the side of the track where the cars derailed was crushed when a car derailed 

and fell over. The student brakeman did not follow instructions given him at a job briefing given by 

the train conductor shortly before the incident occurred.

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

A 24-year-old conductor with 3 months experience died of injuries he sustained when the car he was 

riding on derailed and he was crushed between the car and a steel I-beam.

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

A two person switching crew conducted a job briefing associated with switching operations at an 

industry plant. The crew coupled 10 empty covered hopper cars and commenced the move with the 

conductor riding the B- end of a covered hopper. The car being shoved struck a drainage grate lying 

in the gage of the track and swerved off the track onto a concrete apron of the same height as the 

track. The conductor was trapped between the car and the conrete wall and dragged along the wall 

for a distance of 16 feet, killing him. Clearance between the wall and car was 27 inches; The US 

Deparment of Labor requires a minimum clearance of 30 inches unless the lesser clearance is 

conspicuously marked, which it wasn't.

FE-2008-06 05-Mar-08 WSO Random Lake WI Freight Conductor AGE: 55

A three-person crew (engineer, conductor, and student conductor) arrived at an industrial spot where

they were required to spot 2 loads. This industry had not been spotted for about a month and three 

inches of accumulated snow was covering packed ice on the spur track. The conductor rode the 

leading end of the first car adjacent to the standing train on the main track and the student conductor 

rode the opposite side of the same car, controlling the movement by radio. Due to the build-up of 

packed ice and mud in the flange-way the car derailed into the side of cars left standing on the main 

track, and the conductor was crushed between the cars.
DRAFT 4/8/2011 30 FOR SWG USE ONLY

Special Switching Hazard: Derailment.

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

The conductor of a two person local freight crew was riding the leading end on the side of a tank car

during an industry switching job. The conductor was crushed and killed when the leading car 

derailed and struck a stack of bundled wood railroad ties adjacent to the track. The car derailed on 

compacted aggregate which had been placed as an adhoc crossing on the industry track. The shove 

movement was proceeding at 7 mph on track with a 5 mph maximum speed.

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

A three person crew, operating a freight train on line-of-road, was setting out 30 cars from a 

controlled siding to a yard track. After making the cut on the train the conductor instructed the 

engineer to pull ahead three cars and following a 10 minute interval instructed the engineer to back up

12 cars. After moving about six car lengths the engineer heard and felt a collision. The shove 

movement had collided with the crew’s standing train left foul of the movement. The conductor was

riding the lead car which derailed and turned over, crushing the conductor. The conductor, a set 

back engineer, sent one text message and received three messages while making the cut on the 

controlled siding and making the shove movement into the yard.

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

A two person crew was shoving cars into spot at an industry with the conductor contolling the 

movement via radio communications. The conductor gave car counts from 12 down to 3 during the 

shove, and shortly after that transmission the engineer stopped the movement when he heard an "OH"

transmission. The conductor was found deceased on the leading end of the lead car on the platform,

pinned against a car of scrap metal.

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

A two-person RCL crew shoved five empty cars into a snow-covered industry track. Ice build-up 

on the track caused the lead car of the movement to derail. The RCL operator, riding the lead car and

contolling the move, was crushed against the side of an industry building and fatally injured.

Special Switching Hazard: Drugs and Alcohol.

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

A three person industrial switching crew had been working together to get the switches lined and the 

derail off in preparation for a shove move into the plant. The conductor was on the leading end of the

lead car and the brakeman was on the trailing end of the same car. The conductor was crushed by a 

car he had set out without setting a hand brake. The car rolled into a car he and his brakeman were 

riding and impairment (drugs) contributed to the fatality.
DRAFT 4/8/2011 31 FOR SWG USE ONLY

Special Switching Hazard: Drugs and Alcohol.

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

A three-person crew was in the process of switching a plant when the conductor sent the locomotive

and cars out of one track toward the brakeman who was to handle the switches and direct the cars 

into another track. The conductor stopped the move after the cars had cleared an industry road 

crossing and the engineer waited to receive instructions from the brakeman. However, the brakeman 

had mounted the second head car behind the locomotives and had apparently slipped or fell from that 

position and was found dead by the engineer and conductor lying between and beneath the fourth 

head car. The brakeman tested positive for THCA & THC.

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

A three person switching crew was working in close proximity to another switching crew and, after 

some discussion, but no absolute understanding of the move just made by the other crew, began to 

pull down the switching lead. As they approached a mis-aligned switch, the foreman jumped off the 

moving locomotive, ran to the switch and was in the process of “flopping it over” when the leading 

wheels of the locomotive entered the switch, popped the handle up, striking the foreman in the face 

and killing him. Post accident testing indicated that drug impairment may have contributed to the 

fatality.

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

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

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

the cars via radio, and the engineer stopped one half-car lengths after the last radio transmission of 

one-half cars to go. Subsequently, the engineer discovered that the conductor had stepped in 

between the cars and had been coupled up. 

FE-2004-13 13-May-04 MSO Sturgis MI Conductor AGE: 38

A two person road switching crew was making a shoving movement with the trainmen crossing over

on the brake platform of the lead end of the lead car. The conductor fell from the car and was run 

over by own equipment. The conductor tested positive for THC.

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

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

A two-person freight train crew was about to be passed by another freight train at a location on lineof-road. The conductor of the stopped train got up out of his seat, exited the leading locomotive and 

crossed over the track on which the on-coming train was proceeding. The conductor was struck 

and killed by the lead locomotive of the passing train.
DRAFT 4/8/2011 32 FOR SWG USE ONLY

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

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

A road train pulling around the connection track derailed nine cars while pulling. The student 

brakeman located to the side of the track where the cars derailed was crushed when a car derailed 

and fell over. The student brakeman did not follow instructions given him at a job briefing given by 

the train conductor shortly before the incident occurred.

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

A three person train crew was performing switching operations at an industrial location. The 

brakeman controlling movements by radio, instructed the engineer to back up four cars to a coupling.

 The engineer, watching in the side mirror of the locomotive, noticed the cars moving down curved 

track instead of the straight track to the coupling. The switch target as seen in the mirror indicated 

the switch was lined for the spur track, not the straight track. The engineer saw someone walk in 

front of the movement and it was determined later to be the brakeman, who was struck and killed by 

the erroneous movement. Cellular telephone records indicated the brakeman had made or received 

several telephone calls, including a two-minute call during the time of the fatal shove over the 

misaligned switch. 

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

A three person crew, operating a freight train on line-of-road, was setting out 30 cars from a 

controlled siding to a yard track. After making the cut on the train the conductor instructed the 

engineer to pull ahead three cars and following a 10 minute interval instructed the engineer to back up

12 cars. After moving about six car lengths the engineer heard and felt a collision. The shove 

movement had collided with the crew’s standing train left foul of the movement. The conductor was

riding the lead car which derailed and turned over, crushing the conductor. The conductor, a set 

back engineer, sent one text message and received three messages while making the cut on the 

controlled siding and making the shove movement into the yard.

Special Switching Hazard: Employee Tripping, Slipping, or Falling

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

A four-person crew (engineer, switch foreman, 2 switchman) had 3 cars with them when they 

coupled onto 56 cars standing on a yard track. They were told to pull the head 16 cars and leave the 

remaining 40 there. They were also told that the 16 had been separated from the remaining 40. The 

crew pulled the 19 cars out of the track and per radio instructions from the switchman, began a 

shove into another track. As the movement entered the track it was struck by the 40 car cut that had

been left on the first track. The switchman died falling from the cars while getting on and off the 

free rolling cut to set hand brakes in an attempt to stop them.
DRAFT 4/8/2011 33 FOR SWG USE ONLY

Special Switching Hazard: Employee Tripping, Slipping, or Falling

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

A four person crew (engineer, conductor, 2 brakeman) were in the process of pulling one track out 

and then intended to shove back into another track to pick up more cars. The head brakeman was in 

control of the move. The rear brakeman was found dead adjacent to the track that was pulled. 

Evidence suggests that the rear brakeman may have mounted, or tried to mount the car that ran him 

over as the cut was pulled out of the track.

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

After the brakeman had tied the locomotives onto a cut of cars in the yard, the engineer received an 

instruction, via radio, from the brakeman to “shove to hold more cars.” The engineer began to shove 

and didn’t stop until he was on the other end of the track. The brakeman was run over by the shove 

move. There was no evidence of any other radio transmissions concerning the shove move.

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

A three-person crew was switching an industry. The conductor had directed a few switching moves

and then instructed the engineer to haul out of the plant. The conductor was observed by a plant 

employee riding on the trailing end of the first of two tank cars being pulled out of the plant. 

Moments later the conductor fell between the cars and was killed when he was run over by the 

trailing car in the two car move.

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

A three-person crew was in the process of switching a plant when the conductor sent the locomotive

and cars out of one track toward the brakeman who was to handle the switches and direct the cars 

into another track. The conductor stopped the move after the cars had cleared an industry road 

crossing and the engineer waited to receive instructions from the brakeman. However, the brakeman 

had mounted the second head car behind the locomotives and had apparently slipped or fell from that 

position and was found dead by the engineer and conductor lying between and beneath the fourth 

head car. The brakeman tested positive for THCA & THC.

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

A three-person road crew arrived at a siding, pulled into the siding and stopped their train. They then 

cut off their locomotive consist, ran around the 50 loaded cars in their train, and tied onto the 

opposite end. The conductor and brakeman then positioned themselves on the leading end of the 

shove move and directed the engineer by radio to begin the shove into the plant. As the move entered

a descending grade into the plant, the slack ran out, the conductor lost his hold on the leading car, 

fell in front of the car he was riding, was run over and died.
DRAFT 4/8/2011 34 FOR SWG USE ONLY

Special Switching Hazard: Employee Tripping, Slipping, or Falling

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

A three person yard switching crew was in the process of pulling a five car articulated cut of cars 

from out of one track with the intent of moving them to another. The yard foreman was killed when 

he was run over by the leading wheels of the trailing car. It appears that the foreman tried to release 

a hand brake at the trailing end of the second to the last car and while attempting to do so, stumbled, 

fell and was run over by the trailing car.

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

Yard switch crew, engineer, switch foreman and switchman, were shoving a cut 41 cars up a grade 

to a stop. While this was taking place the ground crew boarded the first two cars so they could apply

the hand brakes. FE (switchman) fell off the first car while attempting this. This car was found to 

have a brake platform with a decreasing width. Under the hand brake this platform was found to be 2

inches under the required width over a length of about 30 inches. FE had 10 months experience.

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

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

moving equipment to open a knuckle while walking backwards.

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

A three person switching crew was shoving a cut of cars into a yard track and the switching 

foreman was riding the leading end of the 35 car cut. There was no air in the train line and the 

engineer was using engine brake to control the shove during the 50 car lengths of clear track to be 

shoved prior to making a coupling on other cars in the same track. Twenty cars into the move the 

foreman was either dislodged or fell from the leading end of the movement and was run over by the 

sixth head car of the shove.

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

A two person crew was switching on the yard lead when the conductor, with 4 years experience, 

gave a "kick" sign via radio. The conductor wearing ice creepers pulled the pin and was struck by 

his own cut of cars and killed.

FE-2004-13 13-May-04 MSO Sturgis MI Conductor AGE: 38

A two person road switching crew was making a shoving movement with the trainmen crossing over

on the brake platform of the lead end of the lead car. The conductor fell from the car and was run 

over by own equipment. The conductor tested positive for THC.
DRAFT 4/8/2011 35 FOR SWG USE ONLY

Special Switching Hazard: Employee Tripping, Slipping, or Falling

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

A two person remote control crew switching in the yard when an empty tank car passed through a 

switch and derailed, this caused the car to shake and bounce violently. The conductor/switchman 

lost his hold on the car and fell off between the rails, and was run over and killed.

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

A road switcher was shoving 60 cars toward cars previously moved. The conductor, riding the cars,

gave the locomotive engineer shoving distances via radio. Following the last transmission, the 

locomotive engineer felt the distance was incorrect, but continued the shove while attempting to 

communicate with the conductor. Failing to contact the conductor, the engineer stopped the 

movement and walked along the cars until he found the conductor's body wedged between the 

wheels of a car. The conductor was fatally injured.

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

An RCL crew consisting of two operators (a conductor and brakeman) were switching 

approximately 60 cars. The crew did a radio job briefing to address movement and three cars were 

moving into a track when the conductor saw the brakeman rolling under the passing cars. As a result

the brakeman was fatally injured.

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

A conductor was in the process of setting 9 cars into a siding when radio communication with the 

engineer stopped. The engineer walked back to check on the conductor and found him under a 

freight car.

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

A four person switching crew free rolled four loaded ingot cars toward track three with the 

conductor, who was to operate the handbrake, riding the leading end of the lead car. When the cars 

did not stop where they should the crew took the locomotive down track three to find the conductor.

 The vertical handbrake support bracket had broken off at the deck of the car and caused the 

conductor to fall and be run over by the cars. The support bracket, which should have been bolted 

to the car, had been welded and the weld failed. 
DRAFT 4/8/2011 36 FOR SWG USE ONLY

Special Switching Hazard: Employee Tripping, Slipping, or Falling

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

A two person road freight train crew was operating on the main track westbound when the engineer 

exited the cab of the controling locomotive to got to the trailing locomotive. The conductor, a 

qualified locomotive engineer, took over operation of the locomotive and train. After several minutes 

when the engineer had not returned, the conductor stopped the train and went in search of the 

engineer and notified the dispatcher. A following westbound train found the engineer on a parallel 

road where he had fallen from the train. The engineer died as a result of injuries sustained in the fall.

Special Switching Hazard: Environment.

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

A three-person yard crew was in the process of switching a plant. The brakeman was at the plant 

doors and the conductor and engineer had hauled out to put away a car that had been removed from 

the plant. After the conductor had tied onto the cars to go into the plant and begun to shove toward 

the plant, the car that had just been placed on an adjacent track rolled out, fouled the conductor’s 

movement, and crushed him between the leading car and the rolling car.

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

A three person local switching crew was shoving a loaded covered hopper down an industrial lead. 

The conductor was riding on one side of the car and the brakeman was riding the other. As the car 

was shoved over a private crossing, the accumulation of ice and snow lifted the car off the rails and 

it tipped over and onto the conductor who was killed as a result of the derailment.

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

A two person switching crew was in the process of switching cars in a storage yard and the 

conductor was riding the leading end of a cut of cars being shoved down a track. The move was 

taking place in dense fog and in darkness when the car he was riding collided with other cars on an 

adjacent track that were fouling the track he was on. The conductor was killed as a result of the collision.

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

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

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

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

on the track that had begun to roll in the same direction as the cars being pull out of the track. 
DRAFT 4/8/2011 37 FOR SWG USE ONLY

Special Switching Hazard: Environment.

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

A two person crew was switching on the yard lead when the conductor, with 4 years experience, 

gave a "kick" sign via radio. The conductor wearing ice creepers pulled the pin and was struck by 

his own cut of cars and killed.

FE-2008-06 05-Mar-08 WSO Random Lake WI Freight Conductor AGE: 55

A three-person crew (engineer, conductor, and student conductor) arrived at an industrial spot where

they were required to spot 2 loads. This industry had not been spotted for about a month and three 

inches of accumulated snow was covering packed ice on the spur track. The conductor rode the 

leading end of the first car adjacent to the standing train on the main track and the student conductor 

rode the opposite side of the same car, controlling the movement by radio. Due to the build-up of 

packed ice and mud in the flange-way the car derailed into the side of cars left standing on the main 

track, and the conductor was crushed between the cars.

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

A two-person RCL crew shoved five empty cars into a snow-covered industry track. Ice build-up 

on the track caused the lead car of the movement to derail. The RCL operator, riding the lead car and

contolling the move, was crushed against the side of an industry building and fatally injured.

Special Switching Hazard: Equipment.

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

This case involved the conductor riding a car into Track 8. The car derailed at the spiked switch and 

the conductor was subsequently killed. The conductor’s last radio transmission was “...we’re lined in

eight rail, three or four cars to a joint.” Movement stopped after car had derailed and side swiped 

adjacent car.

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

A three-person crew reported for duty and later was in the process of shoving cars down a track 

with the switch foreman riding the point. At the same time, another yard switching job was pulling 

cars in the opposite direction on an adjacent track and derailed. The foreman immediately told the 

other crew that they were on the ground and then told his engineer to stop the shove he was riding. 

The foreman was found crushed between the car he was riding and the car that derailed on the adjacent 

track.
DRAFT 4/8/2011 38 FOR SWG USE ONLY

Special Switching Hazard: Equipment.

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

A three-person crew was in the process of switching a plant. The conductor was riding the leading 

end of the lead car during an eight-car shove. He had notified the engineer that he had mounted the 

moving car and told him by radio to continue shoving. When the engineer did not hear any more 

from the conductor, he stopped and the brakeman walked back to find the conductor had been run 

over by five of the eight cars being shoved. An exception was taken by the FRA for the absence of 

the “BR” end handhold that could have been used to assist the conductor in moving from the side of 

the car to the end of the car.

FE-1996-22 03-Sep-96 DGN Dallas TX Brakeman AGE: 43

Yard switch crew, engineer, conductor and brakeman, while switching at an industry on a downhill 

grade experienced an unwanted run away car. While FE (brakeman) was in position on a car and 

setting a hand brake, the car started to roll away from the crew. FE continued to try to apply hand 

brake in an effort to stop the car. When discovering that the car was rolling away, the conductor 

attempted to slow and stop it by putting wood blocks under the wheels. The car accelerate to 30 to 

35 mph. FE did not detrain before car collided with seven other cars at that speed. FE had three weeks 

experience.

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

Three-person crew was switching in class yard, locomotive failed to couple to cut of seven standing 

cars. Yard foreman used hand signals to separate the locomotive by twenty feet. While adjusting the 

locomotive drawbar, the seven cars rolled in and coupled him up.

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

Yard switch crew, engineer, switch foreman and switchman, were shoving a cut 41 cars up a grade 

to a stop. While this was taking place the ground crew boarded the first two cars so they could apply

the hand brakes. FE (switchman) fell off the first car while attempting this. This car was found to 

have a brake platform with a decreasing width. Under the hand brake this platform was found to be 2

inches under the required width over a length of about 30 inches. FE had 10 months experience.

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

A three-person road switcher was in the process of dropping a car into a track. However, the 

locomotive was fouling the track the car was to enter. The brakeman, realizing this, jumped from the

trailing end of the car and ran to the leading end to try and stop the car. The conductor, who was 

standing near the fouling corner of the locomotive, started up the stairwell of the locomotive when he

realized what was happening. However, the stairwell was obstructed with a metal rod that had been 

welded into place and prevented the conductor an escape route. He was subsequently crushed 

between the striking car and the metal rod.
DRAFT 4/8/2011 39 FOR SWG USE ONLY

Special Switching Hazard: Equipment.

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

The engineer and conductor of a road train were told to stop and check their locomotives for flat 

spots. Once stopped, and without a job briefing the locomotive engineer left the lead unit and shortly 

thereafter, was struck and killed by a passing mainline train.

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

A four-person yard switching crew had been working together and classifying cars into various 

tracks throughout the morning. The conductor was on the leading end of a two car free rolling cut 

of cars moving at 3 miles per hours when he fell from the leading end and was run over by the car he

had been riding.

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

A four person switching crew free rolled four loaded ingot cars toward track three with the 

conductor, who was to operate the handbrake, riding the leading end of the lead car. When the cars 

did not stop where they should the crew took the locomotive down track three to find the conductor.

 The vertical handbrake support bracket had broken off at the deck of the car and caused the 

conductor to fall and be run over by the cars. The support bracket, which should have been bolted 

to the car, had been welded and the weld failed. 

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

A lone remote contol operator was working in a yard track coupling cars together to pull to place on 

a departure track. All cars had not coupled properly when switched into the track, and one car had 

the knuckle missing on the end of the car. The operator replaced the knuckle, then began movement 

to couple the track. Shortly after beginning the move to couple, the operator made a radio 

transmission for help when crushed between equipment because drawbars by-passed.

Special Switching Hazard: Failure to Confirm Route of Movement.

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

A three-person crew had arrived at the yard, pulled their train into a track, cut off the engines and 

were given permission to return to the other end of the yard via an adjacent clear track. The 

conductor remained on the end originally entered and the brakeman stayed with the engineer. The 

brakeman got what he thought was the proper switch, instructed the engineer by radio to back up 

and, apparently turned his back on the move. Before the brakeman had a chance to mount the 

returning locomotives, he was struck and killed by the movement that continued for 400 feet before 

stopping when the engineer noticed the brakeman between the gauge of the rail in front of the 

locomotives.
DRAFT 4/8/2011 40 FOR SWG USE ONLY

Special Switching Hazard: Failure to Confirm Route of Movement.

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

Conductor and engineer were moving toward engine house area with lite engines and using hand 

signals. The conductor stopped the movement to line a switch. The engineer while waiting heard and 

acted upon an unidentified radio transmission “come ahead 21.” The engineer initiated the shove 

movement and eventually, the conductor was struck from behind and killed.

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

A three person industry switching crew was in the process of switching cars back and forth over a 

private crossing equipped with an in-ground hand throw switch. The brakeman was at the switch 

and the conductor was going back and forth from one set of cars to another. The conductor shouted

to the brakeman that he wanted the next move down one track but the cars started down the other. 

The brakeman tried to warn the conductor who had his back to the move and then stopped the move 

but to late to save the conductor who was hit and run over by the leading car of the shove.

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

A two-person yard switching crew was in the process of moving their light locomotives to a track 

where it was to be stored for the night. The conductor was on the leading end of the unit and 

directing the move by radio communication. After instructing the engineer to stop, the conductor got

off the locomotive, lined two switches and told the engineer to back up. The engineer backed up 

until he placed the unit at the location where it is always left without further radio contact from his 

conductor. The conductor was struck and killed by the locomotive and found, by the engineer, 

under the locomotive’s fuel tanks.

FE-2004-10 10-Mar-04 MNC Stanford CT Yard Brakeman AGE: 46

A three person crew switching in the yard was building commuter trains. During a shove movement 

the brakeman aligned a power operated switch for a shoving movement, gave instructions to the 

engineer to make the shove, failed to confirm the route of movement, fouled the live track, and was 

struck by the movement. The engineer observed the movement was going down the wrong track but

did not stop the movement until it struck equipment on the track. The engineer looked forward 

following the impact and saw the brakeman lying between the guage of the rail.

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

A conductor was struck and killed by his own cut of cars when he lined switches, thought the cars 

were going to one track, and turned his back of the cars. The cars came back down on the track he 

was fouling, and struck and killed the conductor.
DRAFT 4/8/2011 41 FOR SWG USE ONLY

Special Switching Hazard: Failure to Confirm Route of Movement.

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

A three person train crew was performing switching operations at an industrial location. The 

brakeman controlling movements by radio, instructed the engineer to back up four cars to a coupling.

 The engineer, watching in the side mirror of the locomotive, noticed the cars moving down curved 

track instead of the straight track to the coupling. The switch target as seen in the mirror indicated 

the switch was lined for the spur track, not the straight track. The engineer saw someone walk in 

front of the movement and it was determined later to be the brakeman, who was struck and killed by 

the erroneous movement. Cellular telephone records indicated the brakeman had made or received 

several telephone calls, including a two-minute call during the time of the fatal shove over the 

misaligned switch. 

Special Switching Hazard: Free-Rolling Railcars.

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

A four-person crew (engineer, switch foreman, 2 switchman) had just shoved cars into track 11 and 

held onto one for track 9. The switch foreman got the switch for 9, noticed his front switchman 

standing near cars on track 11, and rode the locomotive onto the lead. After the 11th switch was 

lined for the lead, the switch foreman kicked the single car into track 9. The front switchman was 

struck and killed by the free rolling car.

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

A three-person crew was called to operate a road local and arrived at a location where an eight-car 

drop would be necessary. After a job briefing, the engineer was at the throttle, the conductor at the 

switch and the brakeman was riding the first car of the drop, “A” end. The engineer began to pull, 

the brakeman lifted the pin, the engineer accelerated the locomotive beyond the switch, the conductor

got the switch and the cars began free rolling into the yard. However, the speed of the movement 

would not allow the brakeman to safely dismount and, just before impact with another cut of cars, 

the brakeman attempted to dismount from the car he was riding and was killed as the cars rolled over

him.

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

A three person train crew found it necessary to drop a car by and in doing so, the car hung up 

fouling the switch and blocking the locomotive into the track it had cleared up on. The crew decided 

to “stake” the car to clear the track in which the locomotive sat. This process requires a board or 

pole placed between the locomotive and car to move the car when it cannot be coupled to. The 

brakeman was killed when the board used slipped, the car started to move toward the locomotive and

the brakeman was caught between the two pieces of equipment.
DRAFT 4/8/2011 42 FOR SWG USE ONLY

Special Switching Hazard: Free-Rolling Railcars.

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

Conductor riding side of two cars to be kicked, he moves to the opposite side of car to work hand 

brake and is immediately struck by locomotives standing on adjacent track creating a no-clearance 

condition. Conductor was not aware that the locomotives had arrived at that location since he had last

been there.

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

A three-person work train crew was in the process of dropping 14 cars they thought were empty into

a quarry-loading track. The brakeman was riding the leading and brake end of the car. As the cars 

were separated from the engine, he set the high brake on the car he was riding. However, because 

there were residual materials in many of the cars, the weight added momentum to the cars and the 

brakeman got off and back on between two other cars in an attempt to set more hand brakes. When 

the cut of cars collided with a ballast pile, used as a bumping post, that was located at the end of the 

track, he was crushed to death between the two cars he was trying to apply hand brakes. 

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

Two crews working in the same yard from opposite ends, one crew dropped ten free rolling cars in 

on top of the cut where the other crew’s foreman was installing the E.O.T. at the opposite end. Cars 

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

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

Conductor and switchman making hoses on track 12, last transmission by conductor is “I think I got 

all the hoses after that next one....” Conductor later found to have been struck and killed by a free 

rolling car on the adjacent track.

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

A three person switching crew was in the process of hauling cars over the hump and the foreman of 

the crew was observing the move from between his track and another track that was being used by 

another yard job. The foreman was killed when he fouled and then was struck by a free rolling car 

on the adjacent track.

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

The three-person crew had just finished kicking a flat car into a clear track and the conductor was 

about to mount the leading end of a cut of cars to be kicked into another track further down the lead. 

As the conductor issued instructions to the engineer to begin the move, and to the crew, the flat car 

had not cleared the fouling point to the lead. The shove move rode up onto the flat car derailing the 

car the conductor was riding on which crushed him to death.
DRAFT 4/8/2011 43 FOR SWG USE ONLY

Special Switching Hazard: Free-Rolling Railcars.

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

A two person crew was flat switching in a yard when the switchman, needed a break. He mentioned

it to the yard foreman and they decided to go to break after one last car was “kicked” into a specific 

track. A short time after the car had been released, the foreman’s operating control unit indicated a 

“no poll” failure and the locomotive shut down. When the foreman couldn’t contact the switchman 

he went looking for him. The brakeman was found struck and killed by the last car that had been 

“kicked.”

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

An RCL crew consisting of two operators (a conductor and brakeman) were switching 

approximately 60 cars. The crew did a radio job briefing to address movement and three cars were 

moving into a track when the conductor saw the brakeman rolling under the passing cars. As a result

the brakeman was fatally injured.

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

A three person switching crew working with a student switchman began switching following a safety

briefing. Two rail cars kicked toward a track stalled foul of the clearance point on the adjacent 

track. The next car switched was rolling free when the footboard yardmaster/switch foreman and 

student switchman saw that the cars were fouling the clearance point. The footboard 

yardmaster/switch foreman in an attempt to board and stop the free rolling car became trapped 

between the sides of the cars and carried for a distance between the cars.

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

A road switching assignment while switching cars in the yard, free rolled cars into a yard track, and 

the conductor who was working in the track called via radio stating he had been hurt and needed 

help. The conductor was found in the gauge of track beneath the L-1 wheel of a car. The conductor

later expired due to the injuries sustained.

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

A four person switching crew free rolled four loaded ingot cars toward track three with the 

conductor, who was to operate the handbrake, riding the leading end of the lead car. When the cars 

did not stop where they should the crew took the locomotive down track three to find the conductor.

 The vertical handbrake support bracket had broken off at the deck of the car and caused the 

conductor to fall and be run over by the cars. The support bracket, which should have been bolted 

to the car, had been welded and the weld failed. 
DRAFT 4/8/2011 44 FOR SWG USE ONLY

Special Switching Hazard: Industrial Hazard.

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

A three-person yard crew was in the process of spotting cars over a material unloading pit and after 

the first of the cars was spotted the switch foreman took the locomotive out of the plant building to 

get the other car for spotting. The switchman remained in the building, set a handbrake on the 

spotted car and awaited the return of the foreman with the engine and second car to be spotted. The 

switchman was killed when he ended up falling into the second pit and was crushed by the industrial 

machinery located within.

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

A three person industrial switching crew was shoving three cars down a track. The conductor was 

on the ground, ahead of the move and the brakeman was riding the side of the leading end of the 

leading car. A bush created a clearance issue and the brakeman stepped around the side of the 

leading car to the end of the car just as it began to derail. The brakeman was killed when he fell from the

the derailing car.

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

Crew performing industry switching. Brakeman attempted to couple air hoses while conductor gave 

engineer instructions to shove the movement. Resulting movement was unexpected to brakeman who

was fatally injured.

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

A three-person yard crew was in the process of switching a plant. The brakeman was at the plant 

doors and the conductor and engineer had hauled out to put away a car that had been removed from 

the plant. After the conductor had tied onto the cars to go into the plant and begun to shove toward 

the plant, the car that had just been placed on an adjacent track rolled out, fouled the conductor’s 

movement, and crushed him between the leading car and the rolling car.

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

Yard switch crew, engineer, conductor and brakeman, spotting paper mill. FE (brakeman) instructed 

by conductor to de-train and stay at road crossing while he spotted track. FE found in nearby wood 

chip auger/conveyer system after mill crew started up the system while crew searched for missing 

FE. Mill crew was instructed by conductor not to start equipment until FE was located. FE was not 

familiar with the dangers associated with this mill process. FE had 5 months experience.
DRAFT 4/8/2011 45 FOR SWG USE ONLY

Special Switching Hazard: Industrial Hazard.

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

A three-person crew was called to switch an industry that all were very familiar with. During the 

switching moves, the brakeman was inside an area with no clearances between the cars and the hand 

railings installed on the walls. He was making coupling and, according to the conductor and engineer,

upon completion of that work, ordered the engineer to haul out of the building where the conductor 

would take over the next move to be performed. Subsequently, a plant employee observed the 

brakeman slumped beside the track, rushed to assistance, call 911 and notified the conductor that his 

man was down. The brakeman died later on at the hospital of crushing wounds incurred when he 

was rolled between the cars being pulled out and the railing.

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

Yard crew, engineer, conductor and switchman, switching at an industry. While crew was shoving 

two cars to a spot inside an industry building, FE (switchman) was rolled between lead box car and 

unloading platform. Platform or building was not marked with any type of ‘no-clearance’ or ‘close 

clearance’ signage. FE was last seen by conductor on the ground next to movement in a ‘cut-out’ 

space in the unloading platform. The conductor reported that there is enough room for a man to clear

the movement in this ‘cut-out’. After hearing a strange noise the conductor instructed engineer to 

stop the movement. FE was rolled for 21 feet between boxcar and platform. FE had one year of 

experience.

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

A three person local switching crew (conductor, engineer and utility employee) had just begun to pull 

five cars out of an industrial loading dock while the conductor and the utility employee began to walk 

toward the door providing egress out of the dock area. Suddenly, according to the conductor, the 

utility employee allegedly tripped on some material on the dock, grabbed the side of the outgoing cut 

of cars and was pulled between the car he was holding onto and the handrail structure that 

accompanied the stairs leading from the platform to the door. He died two weeks later.

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

A three person road switching crew was in the process of spotting loaded coal cars at a unloading 

facility that was equipped with a “shaker” that helped empty each car. The shaker’s position causes 

a close clearance condition. The conductor was riding one side of the leading coal car and the 

brakeman was riding the other. Although having a clear view of the fouling equipment, the brakeman

did not get off the car as the conductor had expected and was crushed between it and the fouling 

shaker equipment. 
DRAFT 4/8/2011 46 FOR SWG USE ONLY

Special Switching Hazard: Industrial Hazard.

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

A three person local switching crew was in the process of setting cars into a track within an 

industry. The switchman was riding the side ladder of the leading end of the leading car as it went 

into the building. The doorway would not clear a man riding on the side of the car and the trainman 

was killed as he was compressed between it and the car he was riding.

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

A three person industrial switching crew was shoving one car on a track that ran down the middle of 

a two-lane road and that was located in an industrial area. The conductor was riding on one side of 

the car and the brakeman was riding on the other. As the move approached a standing eighteenwheel truck awaiting permission to back into the same area that the railroad was servicing, the driver 

began to back up, jack-knifed the trailer, and struck the brakeman crushing him between the truck 

box and the car he was riding.

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

Three person crew was spotting cars at industry, when a highway-user (semi-tractor) backed out of 

an unloading location. After completing the backing movement the highway-user pulled forward into 

side of train movement, striking and killing brakeman who was riding the side of equipment.

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

A 24-year-old conductor with 3 months experience died of injuries he sustained when the car he was 

riding on derailed and he was crushed between the car and a steel I-beam.

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

A three person train crew was switching cars on industrial track when the train passed through a 

misaligned crossover switch and colided with a car out to foul on an adjacent track. The trainman 

was crushed on impact against this car.

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

A train crew shoving cars to spot on an induastry track when the brakeman riding the leading end of 

the shove movement, was killed when the movement struck a semi-tractor and trailer which had 

entered the private road crossing in front of the trains movement. The brakeman jumped from the 

car he was riding and the trailer of the semi-trailer jackknifed crushing the brakeman between the 

trailer and rail car.
DRAFT 4/8/2011 47 FOR SWG USE ONLY

Special Switching Hazard: Industrial Hazard.

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

A two person switching crew conducted a job briefing associated with switching operations at an 

industry plant. The crew coupled 10 empty covered hopper cars and commenced the move with the 

conductor riding the B- end of a covered hopper. The car being shoved struck a drainage grate lying 

in the gage of the track and swerved off the track onto a concrete apron of the same height as the 

track. The conductor was trapped between the car and the conrete wall and dragged along the wall 

for a distance of 16 feet, killing him. Clearance between the wall and car was 27 inches; The US 

Deparment of Labor requires a minimum clearance of 30 inches unless the lesser clearance is 

conspicuously marked, which it wasn't.

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

A three person crew prepared to spot cars at a loading dock with the brakeman riding on the cars 

being moved. Clearance at the loading dock is restricted, though no notice of this condition was 

posted. As the engineer proceeded with the shove, the brakeman noticed the conductor was pinned 

between the dock and the car body.

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

A three person switch crew held a job briefing with the intent to deliver 125 car loads of coal onto 

five (5) industry tracks. Only the engineer was familiar with the industry plant and its tracks. The 

engineer offered to operate the locomotive into the plant to allow the rest of the crew to become more

familiar with the work area; the other crew members declined. The track passes under an overhead 

walkway with only 5 1/2 inch clearance between the part of the car on which the brakeman was 

riding, and a support beam of the walkway. The brakeman failed to take heed of this situation and 

was fatally injured when he was crushed between the car and the support member.

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

A train was shoving cars to industry for spotting with the conductor riding the leading end of the 

leading car. A utility employee was providing protection for highway traffic at one of two road 

crossing the train would cross. When the train entered the road crossing it struck a semi-tractor 

trailer and the conductor sustained fatal injuries.

FE-2006-22 04-Dec-06 UP Carson CA Brakeman AGE: 35

A two-person crew, performing switching operation with a remote control locomotive, were in the 

process of shoving six cars over a highway-rail grade crossing equipped with an active warning 

system. The conductor was riding the leading end of the shove move and struck a truck cab that 

drove in front of the movement. The conductor died days later as a result of the collision.
DRAFT 4/8/2011 48 FOR SWG USE ONLY

Special Switching Hazard: Industrial Hazard.

FE-2008-06 05-Mar-08 WSO Random Lake WI Freight Conductor AGE: 55

A three-person crew (engineer, conductor, and student conductor) arrived at an industrial spot where

they were required to spot 2 loads. This industry had not been spotted for about a month and three 

inches of accumulated snow was covering packed ice on the spur track. The conductor rode the 

leading end of the first car adjacent to the standing train on the main track and the student conductor 

rode the opposite side of the same car, controlling the movement by radio. Due to the build-up of 

packed ice and mud in the flange-way the car derailed into the side of cars left standing on the main 

track, and the conductor was crushed between the cars.

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

A three person train crew operated a freight train consisting of three locomotives and 97 loaded coal 

hoppers. The conductor had one year of experience – interrupted by a four month furlough – and a 

student engineer were a part of the train crew. The train crew began shoving to spot the coal 

hoppers into a generating plant. The conductor had not work in this plant previously but was told 

plant employees would help if needed. The conductor rode the shove movement giving car counts 

via radio. The last radio transmission from the conductor to the student engineer, who was operating

the train, was “give me all you’ve got, then “stop.” The lead two cars had plowed through a large 

pile of coal knocking the conductor from the car, crushing the conductor. 

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

The conductor of a two person local freight crew was riding the leading end on the side of a tank car

during an industry switching job. The conductor was crushed and killed when the leading car 

derailed and struck a stack of bundled wood railroad ties adjacent to the track. The car derailed on 

compacted aggregate which had been placed as an adhoc crossing on the industry track. The shove 

movement was proceeding at 7 mph on track with a 5 mph maximum speed.

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

A two person crew performed a shoving movement with the conductor riding the leading end of a 

bulkhead flatcar. A tractor-trailer operated over the crossing in front of the movement. The tractortrailer was moving at about 18 mph when it occupied the crossing protected only by cross bucks in 

front of the train movement. The conductor, who was riding on the crossover platform, radioed the 

engineer in an attempt to stop the movement, but the leading car of the train struck the side of the 

trailer at about 5 mph. The impact crushed and killed the conductor. 
DRAFT 4/8/2011 49 FOR SWG USE ONLY

Special Switching Hazard: Industrial Hazard.

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

A two person crew was shoving cars into spot at an industry with the conductor contolling the 

movement via radio communications. The conductor gave car counts from 12 down to 3 during the 

shove, and shortly after that transmission the engineer stopped the movement when he heard an "OH"

transmission. The conductor was found deceased on the leading end of the lead car on the platform,

pinned against a car of scrap metal.

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

A two-person RCL crew shoved five empty cars into a snow-covered industry track. Ice build-up 

on the track caused the lead car of the movement to derail. The RCL operator, riding the lead car and

contolling the move, was crushed against the side of an industry building and fatally injured.

Special Switching Hazard: Miscellaneous.

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

A three-person yard crew was in the process of spotting cars over a material unloading pit and after 

the first of the cars was spotted the switch foreman took the locomotive out of the plant building to 

get the other car for spotting. The switchman remained in the building, set a handbrake on the 

spotted car and awaited the return of the foreman with the engine and second car to be spotted. The 

switchman was killed when he ended up falling into the second pit and was crushed by the industrial 

machinery located within.

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

A two-person train crew was taking a coal train down a 3 percent grade and through an eight-degree 

curve when the train separated at the 17th head car. The cause of the separation was a broken 

knuckle. To remove the partially broken knuckle, the conductor decided that he had to impact the 

standing cars with the 17 head cars. On his third attempt, the couplers by-passed and the corners of 

the 18th and 17th head cars came together at the push pole pads crushing the conductor between them.

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

A three person switching crew was in the process of shoving cars into a track in the TOFC yard. 

The switch foreman was directing the move when he was struck from behind by the left front fender

of a hostler truck and run over by its rear wheels.
DRAFT 4/8/2011 50 FOR SWG USE ONLY

Special Switching Hazard: Miscellaneous.

FE-1993-22 04-Jun-93 SEPT Devon PA Road Passenger Engineer AGE: 29

A commuter train locomotive engineer fell from the operating compartment of the train he was 

operating while it was moving. Two minutes before he fell speed had been reduced from 61 to 51 

MPH.

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

A three-person crew, accompanied by an engineer and a brakeman trainee, were trying, for the 

second time to make a coupling between two cars in a yard. The conductor was allowing the 

brakeman trainee to learn radio use and had just told him to tell the engineer to come back for another

attempt at coupling. The brakeman turned toward the locomotives, relayed the conductor’s 

instructions, looked back at the conductor and saw him impaled between the knuckles of the two 

cars.

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

A three person switching crew was in the process of shoving cars down an industrial lead. The 

conductor and brakeman were riding the end platform of a tank car and, as the move approached a 

highway/rail grade crossing, the brakeman gave the engineer a car count in which to stop. As a 

result, there was some “slack action” and the conductor fell from the end platform onto the rail and 

was pronounced dead at the hospital over five hours later.

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

A three-person crew was called to operate a road local and arrived at a location where some plant 

switching was to take place. After lining up their cars, the two locomotives and two cars began a 

shove move on the brakeman’s radio command. The brakeman was walking adjacent to the track on

which the cars were being shoved and had his back to the move. He was killed when he suddenly 

crossed the tracks in front of the movement and was struck. The move stopped immediately. Post 

accident investigation revealed that the brakeman was concerned about the results of a medical 

examination that were due the next day.

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

An engineer, having just gone off duty, was distracted and subsequently struck and killed by a lite 

engine move being operated by a hostler. The hostler was operating the locomotive consist from the 

trailing end at the time and did not have anyone on the leading end when the engineer was struck.
DRAFT 4/8/2011 51 FOR SWG USE ONLY

Special Switching Hazard: Miscellaneous.

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

A three person yard switching crew was in the process of moving their light locomotives through a 

series of crossover switches however, the switchman had gone to the yard office for another list of 

cars to switch and the foreman, who had two (2) years of service, was directing the lite engine move

by radio. The foreman told the engineer to stop, the foreman got off the leading end of the lead 

locomotive to line switches, he then told the engineer to continue backing up. Shortly thereafter, the 

foreman was crushed in a side collision between the locomotive consist he was directing and other 

cars standing on an adjacent track. 

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

The conductor of a road switcher pulled his train into a yard, got off, made a cut behind three cars 

and told the engineer to pull ahead to clear a crossover switch he intended to use. After getting the 

crossover, he mounted the leading end of the move and told the engineer to come back seven cars. 

Three car lengths later, the movement passed through one end of another crossover switch in reverse

position and diverted the movement into the side of a standing cut of cars crushing the conductor to 

death.

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

A road train after contacting the yard switcher, obtained permission to enter the yard to set out 24 

cars. When the road train cleared the yard the switcher train resumed switching activities in the yard,

and following a shove movement toward a yard track, the conductor on the yard switcher saw the 

body of road train’s brakeman between the rails in front of the yard switcher locomotive.

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

A three person train crew was switching cars on industrial track when the train passed through a 

misaligned crossover switch and colided with a car out to foul on an adjacent track. The trainman 

was crushed on impact against this car.

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

A Utility Man working on Track 11 was bleeding the air from cars to be humped. An RCL job, 

working on Track 10, prepared to shove 84 cars toward the “hump.” Following their shove to the 

“hump” the utility employee was found dead on track 10, having been run over by the shove 

movement. The Coroner’s report suggested suicide. 
DRAFT 4/8/2011 52 FOR SWG USE ONLY

Special Switching Hazard: Miscellaneous.

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

A two person road train crew was doubling back to their train on main track one with the conductor 

walking between main track one and main track two giving hand signals to the engineer. The 

conductor was fouling main track two when another train operating on main track two struck and 

killed the conductor. A van driver located across from the conductor's position attempted to warn 

the conductor by yelling at him.

Special Switching Hazard: Struck by Mainline Train.

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

A two-person crew was called to deadhead to a siding and bring the train that was there and tied 

down into the yard. Upon arrival at the train, the conductor began releasing handbrakes on the train 

and the engineer began releasing handbrakes and inspecting the four head end locomotives. An 

approaching 60 MPH mainline train whistled for a highway crossing at grade and the conductor 

stopped what he was doing and positioned himself to do a roll by train inspection. His engineer was 

killed when he was struck by the passing train as he stepped out from between two of his units and 

began walking adjacent to, and in the foul of, the main track.

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

A three-person crew reported for duty and was transported to a location where they took control of a

mainline train. En-route, their work included swapping rear end marking devices. The brakeman 

apparently became confused, stepped into and began walking within the gauge of the main track, and 

was struck in the back by a passing mainline train.

FE-1996-17 07-Jul-96 NS Sidney IN Conductor AGE: 29

Road crew, engineer and conductor, while stopped on siding track to meet an opposing train, FE 

(conductor) detrained to perform a roll-by inspection of other train. FE stepped off his train shortly 

before opposing trains arrival then stood in that trains track while trying to adjust his portable radio. 

Opposing train struck FE at this point. FE had one year of experience.

FE-1997-22 18-Jul-97 MNC Stamford CT Conductor AGE: 40

A conductor/flagman was assigned to protect contractor workers that were installing construction 

poles near a passenger station platform. To better observe the work, the conductor/flagman placed 

himself within the gauge of a “live” main track and was struck and killed by a passing train.
DRAFT 4/8/2011 53 FOR SWG USE ONLY

Special Switching Hazard: Struck by Mainline Train.

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

The three-person crew had just finished making up their train at the yard. The conductor, for 

unknown reasons, had positioned himself on the “live” main trackside of his train, near the second 

and third locomotives. The conductor was struck and killed by a passing main track train that had 

approached the area from the opposite direction than that the conductor’s train was to proceed.

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

A three-person yard switching crew was in the process of pulling cars down a long lead that ran 

parallel to a main track. The switchman was standing between the cars that were being pulled out 

onto the lead and the main track. While the cars were being moved, a main line train approached his 

location. The switchman, with nowhere to go, was struck by the passing main line train and killed by

a blow to the head.

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

A two-person freight train crew was about to be passed by another freight train at a location on lineof-road. The conductor of the stopped train got up out of his seat, exited the leading locomotive and 

crossed over the track on which the on-coming train was proceeding. The conductor was struck 

and killed by the lead locomotive of the passing train.

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

Conductor with 14-months service was struck and killed by passing mainline train while attempting to

board locomotive at crew-change point.

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

The engineer and conductor of a road train were told to stop and check their locomotives for flat 

spots. Once stopped, and without a job briefing the locomotive engineer left the lead unit and shortly 

thereafter, was struck and killed by a passing mainline train.

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

A conductor, engineer and conductor in training had been transported to an unattended train standing 

on a siding a portion of which was in a tunnel adjacent to the main track. After storing their 

equipment, the conductor and the conductor in training left the locomotive to release hand brakes on 

the train. The conductor was killed when she failed to step in between two boxcars of her train as the

conductor in training had done and was subsequently struck by a passing mainline train. 
DRAFT 4/8/2011 54 FOR SWG USE ONLY

Special Switching Hazard: Struck by Mainline Train.

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

A locomotive engineer had been dropped off at the head end of his train while the conductor was 

taken to the rear to check on the REM. After crossing over the ATK corridor mainline tracks, and 

beginning to board his locomotive, the engineer was dragged off the stairs of the locomotive and 

killed by a passing 110 MPH passenger train. 

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

An eastbound train stopped on the siding waiting the passage of a westbound train. The engineer saw

the headlight of the approaching train, and observed his conductor get up and exit on the live track 

side of the locomotive, contrary to rules. While attempting to cross to the other side of the track to 

conduct an inspection, the conductor paused in the middle of the track and the approaching train, 

sounding the horn and with headlight on bright, struck the conductor still standing on the track.

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

An eastbound train was stopped on the siding waiting for the passage of two westbound trains. The 

first train, approaching at a speed of 20 -23 mph, was observed by the engineer and heard the train 

sounding its whistle and bell. The conductor on the standing train got up and without a word, 

departed the locomotive's cab to conduct a roll-by inspection and stepped off the standing train 

locomotive on the live side between tracks. The approaching train struck the conductor, killing the 

conductor.

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

A two person crew experienced engine problems and a following train, after a job briefing involving 

the crews of the two trains and the Dispatcher, decided the following train would shove the lead train

off the main track onto a siding. In the process of shoving, the conductor of the leading train 

dismounted a covered hopper car and was struck and killed by the other train passing on the adjacent 

track. The accident occurred on a curved section of track, in a restricted speed zone. Had a bell or 

whistle been sounded, or had the Conductor dismounted on the other side of his train, the accident 

might have been avoided.
DRAFT 4/8/2011 55 FOR SWG USE ONLY

Special Switching Hazard: Struck by Mainline Train.

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

A four-person commuter train crew (No. 355) arrived at their destination station and prepared to 

back the train from the northbound track through the crossovers south of the platform, and onto the 

southbound track where it would be worked as a southbound train by another crew. The crew would

then go off-duty. Ordinarily, the brakeman would line both switches. However, the Extraboard 

Engineer while backing the train through the crossovers shouted down to the Brakeman that he would

get the south crossover switch when the engine cleared it and stopped. The Brakeman agreed and 

stayed at the north cross-over switch. After the Engineer aligned the switch and returned to the 

locomotive cab. The Brakeman walking south toward the train gave the Engineer two confusing, 

contradictory signals. As the Brakeman was stooping to examine or attempting to line the south 

crossover switch (which the Engineer had already lined), a following train (No. 357) moving 

northward on Main Track No. 1 passed the head-end of job No. 355 and struck the brakeman killing 

him. The striking train was not ringing the locomotive’s bell as it passed the standing train.

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

A conductor and engineer were transported to their train on main track two and boarded. The 

ground conditions between main tracks two and one were very poor. The ground was covered by 5 

inches of snow; however, the ambient lighting was good. On the south side of the standing train, the

footing was good, but the lighting was poor. After receiving 3-Point Protection, the conductor 

dismounted the lead locomotive and proceeded to walk west, between the two main tracks, on the 

north side of his standing train, to untie handbrakes. An approaching westbound freight train 

sounded the whistle for the conductor walking in the foul and the conductor ducked between two 

freight cars to clear the oncoming movement. The conductor then reemerged from his safe location 

foul of the adjacent main track. He was struck by the westbound train and died 42 hours later. 

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

After reaching their destination, a two person crew was instructed to secure their freight train at a 

location beyond the normal crew change point. The location was on double track on a bridge near a 

parking lot where a relief crew could reach the train. The conductor left the cab of the locomotive 

without job-briefing with the Engineer and without his hand-held radio. He crossed in front of the 

locomotive and walked eastward across the bridge between the two tracks. There was poor footing 

and almost no clearance between the two tracks. An eastbound approaching train, operating at 26 

mph, observed the conductor, sounded the whistle, turned the head lights to bright, and tried to stop. 

The eastbound train struck and killed the conductor who was walking in the foul. 

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

A four person yard switching crew was pulling cars up to make a shoving movement into a yard 

track, while a road train was approaching in the same direction on the main track adjacent to the 

switching lead. The conductor riding in the second locomotive of the yard switcher exited the cab 

and got off on the live side next to the main track, fouling the main track, and was struck by the passing 

road train.
DRAFT 4/8/2011 56 FOR SWG USE ONLY

Special Switching Hazard: Struck by Mainline Train.

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

A two person crew had boarded their train on main track two and the conductor began walking the 

train making an inspection. At that time another train approaching on main track one observed the 

conductor walking in the foul of main track one. The engineer on the approaching train switched the 

headlight from dim to bright to alert the conductor on the ground. A van driver beside the track also 

attempted to get the attention of the conductor without success. The train on main track two struck 

and killed the conductor.

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

A two person road train crew was doubling back to their train on main track one with the conductor 

walking between main track one and main track two giving hand signals to the engineer. The 

conductor was fouling main track two when another train operating on main track two struck and 

killed the conductor. A van driver located across from the conductor's position attempted to warn 

the conductor by yelling at him.

Special Switching Hazard: Struck or struck by Motor Vehicle.

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

A three-person work train crew was shoving their train on the main line. The locomotive engineer 

was operating the locomotive and the brakeman and conductor were in the caboose. A tractor-trailer 

pulled over the crossing and was struck by the shove move, derailing the caboose and killing the 

brakeman.

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

A three person switching crew was working in a piggy-back facility and had just finished shoving a 

cut of cars down a track to be worked by the piggy-packers (equipment used to load and unload 

TOFC/COFC rail shipments). The conductor was returning to the locomotive when he was struck 

and killed by one of the piggy-packers.

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

A three-person, local switching crew that included a conductor in training were in the process of 

shoving a cut of cars over a highway road crossing at grade. The brakeman was riding one corner of

the leading car and the conductor in training was riding the opposite side of the car. All warning 

devices were in operation when a van struck the leading end of the car knocking the brakeman off 

the car and under the leading wheels.
DRAFT 4/8/2011 57 FOR SWG USE ONLY

Special Switching Hazard: Struck or struck by Motor Vehicle.

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

A three person industrial switching crew was shoving one car on a track that ran down the middle of 

a two-lane road and that was located in an industrial area. The conductor was riding on one side of 

the car and the brakeman was riding on the other. As the move approached a standing eighteenwheel truck awaiting permission to back into the same area that the railroad was servicing, the driver 

began to back up, jack-knifed the trailer, and struck the brakeman crushing him between the truck 

box and the car he was riding.

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

Three person crew was spotting cars at industry, when a highway-user (semi-tractor) backed out of 

an unloading location. After completing the backing movement the highway-user pulled forward into 

side of train movement, striking and killing brakeman who was riding the side of equipment.

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

A train crew shoving cars to spot on an induastry track when the brakeman riding the leading end of 

the shove movement, was killed when the movement struck a semi-tractor and trailer which had 

entered the private road crossing in front of the trains movement. The brakeman jumped from the 

car he was riding and the trailer of the semi-trailer jackknifed crushing the brakeman between the 

trailer and rail car.

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

A train was shoving cars to industry for spotting with the conductor riding the leading end of the 

leading car. A utility employee was providing protection for highway traffic at one of two road 

crossing the train would cross. When the train entered the road crossing it struck a semi-tractor 

trailer and the conductor sustained fatal injuries.

FE-2006-22 04-Dec-06 UP Carson CA Brakeman AGE: 35

A two-person crew, performing switching operation with a remote control locomotive, were in the 

process of shoving six cars over a highway-rail grade crossing equipped with an active warning 

system. The conductor was riding the leading end of the shove move and struck a truck cab that 

drove in front of the movement. The conductor died days later as a result of the collision.
DRAFT 4/8/2011 58 FOR SWG USE ONLY

Special Switching Hazard: Struck or struck by Motor Vehicle.

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

A two person crew performed a shoving movement with the conductor riding the leading end of a 

bulkhead flatcar. A tractor-trailer operated over the crossing in front of the movement. The tractortrailer was moving at about 18 mph when it occupied the crossing protected only by cross bucks in 

front of the train movement. The conductor, who was riding on the crossover platform, radioed the 

engineer in an attempt to stop the movement, but the leading car of the train struck the side of the 

trailer at about 5 mph. The impact crushed and killed the conductor. 

Special Switching Hazard: Unexpected Movement of Railcars.

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

Road switcher R90371-26, was switching cars at Fulton Yard in Fulton, Kentucky. The conductor 

on the job had ridden shove movement into track seven and secured car and remained at that location 

while the remainder of the crew switched cars between track seven and track five. At 4:25 a.m., 

after free rolling the last car into track seven, and while coupling to cars on lead to shove clear of 

track six, the conductor called via the radio and stated he had been hurt. The conductor was found 

beneath the L-1 wheel of GATX 10818 in the gauge of track seven and later expired due to injuries 

sustained.

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

The road job’s brakeman was trying to help the switch crew make up his train. The brakeman was in

between cars on an active track being used by the switch crew and was killed when the cars he was

between moved upon being struck by a cut of free rolling cars. 

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

Crew performing switching duties in class yard failed to have a clear understanding of movements 

being made. Results were that the rear brakeman was run over by moving equipment. There were no 

witnesses, but a hand brake was applied. It was thought that the brakeman had gone between the 

equipment on the ground to release the low hand brake.

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

Trainmaster became involved with crew performing switching in class yard without knowledge of 

the conductor who was coupling air hoses on a cut of cars. Cars were shoved without his knowledge

while he was in the foul of the movement. Movement ran over conductor and killed him. 
DRAFT 4/8/2011 59 FOR SWG USE ONLY

Special Switching Hazard: Unexpected Movement of Railcars.

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

Change in operating procedure between two crews swapping equipment resulted in conductor being 

struck by unexpected movement while he was in the foul of the track. 

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

Crew switching in class yard failed to establish and maintain effective communications. Subsequent 

changes in switching line-up by the conductor resulted in trainman who was in the foul of Track 7 

being struck by unexpected movement of equipment.

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

Arbitrary change in switching operations by conductor resulted in him being unexpectedly struck and 

fatally injured by approaching cars while he was fouling the track.

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

The engineer and conductor of a local road switcher were reassembling their train at a siding halfway

through their work assignment. After running around the inbound cars, making a couple of switches

to line up their train for the return trip, the conductor tied the EOT device onto the rear car, came 

back to the switch, and told the engineer to back up five cars. The engineer did not get any other 

radio instructions after three cars and stopped. The conductor was found dead having been run over 

by the leading car and not having reversed the siding switch as he had intended to do.

FE-1999-32 17-Nov-99 UP Linoln NE Brakeman AGE: 57

A three person local switching crew had cut away from their train on the main track and proceeded 

to pull by the switch providing access to a clear track. The brakeman was at the switch and the 

conductor had removed the derail from the clear track and was awaiting the shove move at the point 

where the cut would be made. Meanwhile, the brakeman, who was to have gotten the switch from 

the main to the clear track, was walking between the gauge of the mainline track toward the 

remaining portion of his train. The conductor saw the cars being shoved toward the remaining 

portion of his train and shouted to the brakeman and then to the engineer to stop. The brakeman with

his back to the move was hit and run over by the leading car of the shove.

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

A two-person road crew stopped at a yard to make a set-off. The conductor made the cut on his 

train, instructed the engineer to haul ahead to clear the switches into the yard, lined the switches into 

what he thought was Track 4 and told the engineer to begin backing the set off into the yard. The 

conductor was struck and killed by the leading end of the shove move as it entered Track 3. 
DRAFT 4/8/2011 60 FOR SWG USE ONLY

Special Switching Hazard: Unexpected Movement of Railcars.

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

A pitch/catch remote control operation was being run by a single operator who was struck and killed 

during a yard operation by his own locomotive. He stepped in front of its movement as he was 

headed for the other end of a crossover switch that he intended to line for the route he intended his 

engine to use.

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

A three person crew, operating a local freight train, moved their locomotives to a make-up track. 

After a job briefing, the switchman proceeded to make sure the train was together and the air hoses 

were coupled. The switchman did not observe sixteen cars at the end of the train were not coupled. 

A few minutes later, he radioed he was going between to make an air hose. The Engineer said: “Set 

and centered.” A few minutes earlier, the Conductor was walking the head-end and found a gap. 

Without communicating with the Switchman, the Conductor instructed the Engineer to pull forward 

so that he could open knuckles and prepare for a reverse movement to a coupling. Apparently, when 

the train moved forward, the 16 cars at the rear of the train began to roll, just as the Switchman was 

reaching in to connect an air hose. The 16 free-rolling cars struck the standing portion of the train 

and killed the Switchman. 

Special Switching Hazard: Unsecured Cars.

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

A four-person crew (engineer, switch foreman, 2 switchman) had 3 cars with them when they 

coupled onto 56 cars standing on a yard track. They were told to pull the head 16 cars and leave the 

remaining 40 there. They were also told that the 16 had been separated from the remaining 40. The 

crew pulled the 19 cars out of the track and per radio instructions from the switchman, began a 

shove into another track. As the movement entered the track it was struck by the 40 car cut that had

been left on the first track. The switchman died falling from the cars while getting on and off the 

free rolling cut to set hand brakes in an attempt to stop them.

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

A three person industrial switching crew had been working together to get the switches lined and the 

derail off in preparation for a shove move into the plant. The conductor was on the leading end of the

lead car and the brakeman was on the trailing end of the same car. The conductor was crushed by a 

car he had set out without setting a hand brake. The car rolled into a car he and his brakeman were 

riding and impairment (drugs) contributed to the fatality.
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Special Switching Hazard: Unsecured Cars.

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

A three-person crew were in the process of pulling a cut of cars out of a track and leaving two 

additional cuts sitting separately in the track. The helper was riding the cut out of the track and the 

foreman was last seen walking between the two remaining cuts of cars. Evidence suggests that the 

foreman attempted to cross over the tracks between the cars being pulled out and the first of two 

remaining cuts of cars when he was crushed between the cars being pulled out and the second cut of

cars after they were impacted by the third, unsecured cut.

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

A two-person crew was switching at a siding in single-track territory. The conductor left a portion 

of his train on the mainline and went into the siding with a cut of cars. While in on the siding, the 

cars left on the mainline and, as post accident investigation revealed, had been left with the air 

“bottled”, rolled away. The crew chased the runaway cars with the conductor riding the leading end 

of the lead car and the engineer, 23 cars away, shoving as directed by radio commands from the 

conductor. The shove move struck the runaway cars and the conductor was crushed to death as a result 

of the collision.

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

Three-person crew was switching in class yard, coupling between sixth and seventh car failed to 

couple. Conductor stopped locomotive and went between the cars to straighten the drawbar, and 

twenty-three cars rolled in behind him and coupled him up.

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

A three-person yard crew was in the process of switching a plant. The brakeman was at the plant 

doors and the conductor and engineer had hauled out to put away a car that had been removed from 

the plant. After the conductor had tied onto the cars to go into the plant and begun to shove toward 

the plant, the car that had just been placed on an adjacent track rolled out, fouled the conductor’s 

movement, and crushed him between the leading car and the rolling car.

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

Crew was switching in class yard. Helper was attempting to adjust the drawbar in order to couple to 

three cars about forty feet away that had not coupled the first time. While adjusting the drawbar, the 

helper did not notice the three free-rolling cars coming back in on him and the cars coupled him up.

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

Crew was working in one track in class yard with helper controlling engine moves, conductor was 

adjusting coupler when three free rolling cars struck him from behind and coupled him up.
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Special Switching Hazard: Unsecured Cars.

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

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

adjust the coupler or drawbar.

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

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

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

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

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

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

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

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

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

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

A three person switching crew was in the process of shoving cars into a track at an industry. The 

switch foreman was riding the leading end of the shove and directing the move when he was struck 

by the cut of cars that they had left on another track and which had rolled out and into his shove move.

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

A conductor while engaged in switching operations attempted to uncouple freight cars from the 

locomotive, and was caught between the locomotive and these cars. The cars had not had their 

brakes secured as operating rules dictated they should. The conductor was killed.

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

During a flat switch operation, the conductor attempted to couple cars attached to his locomotive 

with 2 cars standing on the track. The coupling did not occur and a short time later, the conductor 

was found run over by one of the two standing cars.

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

A three person crew switchig at an industry was trying to control equipment that failed to couple to 

equipment left on the main track. While attempting to stop the equipment the brakeman was pulled 

between the equipment that fouled on an adjacent track and was crushed.
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Fatalities During The Second Hour of Duty

FE-1992-03 1/28/1992 BN Willmar MN Yard Brakeman/Helper AGE: 57

A four-person crew (engineer, switch foreman, 2 switchman) had just shoved cars into track 11 and

held onto one for track 9. The switch foreman got the switch for 9, noticed his front switchman 

standing near cars on track 11, and rode the locomotive onto the lead. After the 11th switch was 

lined for the lead, the switch foreman kicked the single car into track 9. The front switchman was 

struck and killed by the free rolling car.

FE-1992-33 10/15/1992 BN Omaha NE Yard Brakeman/Helper AGE: 32

A three-person yard crew was in the process of spotting cars over a material unloading pit and after 

the first of the cars was spotted the switch foreman took the locomotive out of the plant building to 

get the other car for spotting. The switchman remained in the building, set a handbrake on the

spotted car and awaited the return of the foreman with the engine and second car to be spotted. The

switchman was killed when he ended up falling into the second pit and was crushed by the industrial

machinery located within.

FE-1993-26 7/15/1993 CR Anderson IN Yard Brakeman/Helper AGE: 43

After the brakeman had tied the locomotives onto a cut of cars in the yard, the engineer received an 

instruction, via radio, from the brakeman to “shove to hold more cars.” The engineer began to shove

and didn’t stop until he was on the other end of the track. The brakeman was run over by the shove

move. There was no evidence of any other radio transmissions concerning the shove move.

FE-1993-35 9/2/1993 ATSF Carlsbad NM Freight Conductor AGE: 55

A three-person crew, accompanied by an engineer and a brakeman trainee, were trying, for the 

second time to make a coupling between two cars in a yard. The conductor was allowing the 

brakeman trainee to learn radio use and had just told him to tell the engineer to come back for 

another attempt at coupling. The brakeman turned toward the locomotives, relayed the conductor’s 

instructions, looked back at the conductor and saw him impaled between the knuckles of the two cars.

FE-1993-53 12/30/1993 CR Brook Park OH Yard Conductor/Foreman AGE: 61

A three-person yard crew was in the process of switching a plant. The brakeman was at the plant 

doors and the conductor and engineer had hauled out to put away a car that had been removed from 

the plant. After the conductor had tied onto the cars to go into the plant and begun to shove toward 

the plant, the car that had just been placed on an adjacent track rolled out, fouled the conductor’s 

movement, and crushed him between the leading car and the rolling car.
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Fatalities During The Second Hour of Duty

FE-1994-02 1/4/1994 BN Hastings NE Conductor AGE: 46

A three-person crew were in the process of pulling a cut of cars out of a track and leaving two 

additional cuts sitting separately in the track. The helper was riding the cut out of the track and the 

foreman was last seen walking between the two remaining cuts of cars. Evidence suggests that the 

foreman attempted to cross over the tracks between the cars being pulled out and the first of two 

remaining cuts of cars when he was crushed between the cars being pulled out and the second cut 

of cars after they were impacted by the third, unsecured cut.

FE-1994-04 1/18/1994 CSXT Bainbridge GA Conductor AGE: 45

A three person switching crew was in the process of shoving cars down an industrial lead. The 

conductor and brakeman were riding the end platform of a tank car and, as the move approached a 

highway/rail grade crossing, the brakeman gave the engineer a car count in which to stop. As a 

result, there was some “slack action” and the conductor fell from the end platform onto the rail and 

was pronounced dead at the hospital over five hours later.

FE-1994-29 11/15/1994 CR Painted Post NY Freight Brakeman/Flagman AGE: 57

Crew switching in class yard failed to establish and maintain effective communications. Subsequent 

changes in switching line-up by the conductor resulted in trainman who was in the foul of Track 7 

being struck by unexpected movement of equipment.

FE-1995-17 3/21/1995 SP Bassett CA Conductor AGE: 55

A three-person crew was called to operate a road local and arrived at a location where some plant 

switching was to take place. After lining up their cars, the two locomotives and two cars began a 

shove move on the brakeman’s radio command. The brakeman was walking adjacent to the track 

on which the cars were being shoved and had his back to the move. He was killed when he 

suddenly crossed the tracks in front of the movement and was struck. The move stopped 

immediately. Post accident investigation revealed that the brakeman was concerned about the results

of a medical examination that were due the next day.

FE-1995-29 10/4/1995 CSXT Riverdale IL Conductor AGE: 39

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

a mis-aligned coupler on the fifteenth car after the cut was stretched. Switch foreman was facing 

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

FE-1998-15 5/26/1998 BRC Bedford Park IL Yard Conductor/Foreman AGE: 57

Crew was working in one track in class yard with helper controlling engine moves, conductor was 

adjusting coupler when three free rolling cars struck him from behind and coupled him up.
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Fatalities During The Second Hour of Duty

FE-1999-14 5/19/1999 NS Cincinnati OH Conductor AGE: 36

A conductor with one year of service was riding in the stairwell of the leading locomotive. He was 

directing the move by radio when he realized to late that the move would not clear the standing 

equipment. He was crushed between the handrail of his locomotive and the standing locomotive.

FE-2000-13 4/21/2000 BNSF Galesburg IL Engine Foreman AGE: 60

A three person switching crew was in the process of hauling cars over the hump and the foreman of

the crew was observing the move from between his track and another track that was being used by 

another yard job. The foreman was killed when he fouled and then was struck by a free rolling car 

on the adjacent track.

FE-2000-21 7/7/2000 CKRY Wichita KS Conductor AGE: 39

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

between moving equipment to open a knuckle while walking backwards.

FE-2000-32 12/28/2000 UP Dupo IL Switchman AGE: 52

A three-person yard switching crew was in the process of pulling cars down a long lead that ran 

parallel to a main track. The switchman was standing between the cars that were being pulled out 

onto the lead and the main track. While the cars were being moved, a main line train approached his 

location. The switchman, with nowhere to go, was struck by the passing main line train and killed 

by a blow to the head.

FE-2001-14 4/8/2001 BNSF Clark OK Conductor AGE: 35

The conductor of a road switcher pulled his train into a yard, got off, made a cut behind three cars 

and told the engineer to pull ahead to clear a crossover switch he intended to use. After getting the 

crossover, he mounted the leading end of the move and told the engineer to come back seven cars. 

Three car lengths later, the movement passed through one end of another crossover switch in 

reverse position and diverted the movement into the side of a standing cut of cars crushing the 

conductor to death.

FE-2002-12 5/14/2002 UP Pine Bluff AR Switchman AGE: 53

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

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

align the couplers. The switchman was coupled up when unsecured cars rolled in on him. 
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Fatalities During The Second Hour of Duty

FE-2003-03 2/11/2003 CNIC Flat Rock MI Brakeman AGE: 57

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

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

in the process of shoving a cut of cars down a track that was located between where the 

brakeman’s crew were waiting and the Shanty. The brakeman exited the Shanty and was struck by 

the shove move as he crossed the tracks to get to his crew. The shove move was being preceded 

by two of the striking train’s crew who were riding in a van at the time.

FE-2003-04 2/16/2003 CSXT Syracuse NY Switchman AGE: 36

A two person crew was flat switching in a yard when the switchman, needed a break. He 

mentioned it to the yard foreman and they decided to go to break after one last car was “kicked” into

a specific track. A short time after the car had been released, the foreman’s operating control unit 

indicated a “no poll” failure and the locomotive shut down. When the foreman couldn’t contact the 

switchman he went looking for him. The brakeman was found struck and killed by the last car that 

had been “kicked”.

FE-2003-12 6/6/2003 CSXT Kingsport TN Brakeman AGE: 35

A three person industrial switching crew was shoving one car on a track that ran down the middle of

a two-lane road and that was located in an industrial area. The conductor was riding on one side of 

the car and the brakeman was riding on the other. As the move approached a standing eighteenwheel truck awaiting permission to back into the same area that the railroad was servicing, the driver

began to back up, jack-knifed the trailer, and struck the brakeman crushing him between the truck 

box and the car he was riding.

FE-2003-35 12/7/2003 UP San Antonio TX Conductor AGE: 37

A pitch/catch remote control operation was being run by a single operator who was struck and killed

during a yard operation by his own locomotive. He stepped in front of its movement as he was 

headed for the other end of a crossover switch that he intended to line for the route he intended his 

engine to use.

FE-2004-20 9/2/2004 BNSF Clovis NM Conductor/switchman AGE: 26

A two person remote control crew switching in the yard when an empty tank car passed through a 

switch and derailed, this caused the car to shake and bounce violently. The conductor/switchman 

lost his hold on the car and fell off between the rails, and was run over and killed.

FE-2007-21 10/27/2007 CSX Russell KY Yard Foreman AGE: 52

A 52 year old yard foreman with 6 months service was crushed and killed while riding the leading 

end of a five locomotive consist when it passed through a mis-aligned crossover switch and collided 

with a standing train on an adjacent track.
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Fatalities During The Second Hour of Duty

FE-2007-25 12/28/2007 BNSF Bristol IL Freight Brakeman AGE: 62

A three person crew switchig at an industry was trying to control equipment that failed to couple to 

equipment left on the main track. While attempting to stop the equipment the brakeman was pulled 

between the equipment that fouled on an adjacent track and was crushed.

FE-2008-01 1/8/2008 UP Waukegan IL Passenger Brakeman AGE: 59

A four-person commuter train crew (No. 355) arrived at their destination station and prepared to 

back the train from the northbound track through the crossovers south of the platform, and onto the 

southbound track where it would be worked as a southbound train by another crew. The crew 

would then go off-duty. Ordinarily, the brakeman would line both switches. However, the 

Extraboard Engineer while backing the train through the crossovers shouted down to the Brakeman 

that he would get the south crossover switch when the engine cleared it and stopped. The Brakeman 

agreed and stayed at the north cross-over switch. After the Engineer aligned the switch and returned 

to the locomotive cab. The Brakeman walking south toward the train gave the Engineer two 

confusing, contradictory signals. As the Brakeman was stooping to examine or attempting to line the 

south crossover switch (which the Engineer had already lined), a following train (No. 357) moving 

northward on Main Track No. 1 passed the head-end of job No. 355 and struck the brakeman killing 

him. The striking train was not ringing the locomotive’s bell as it passed the standing train 

FE-2008-03 2/3/2008 NS Chicago IL Freight Conductor AGE: 28

A conductor and engineer were transported to their train on main track two and boarded. The 

ground conditions between main tracks two and one were very poor. The ground was covered by 5

inches of snow; however, the ambient lighting was good. On the south side of the standing train, 

the footing was good, but the lighting was poor. After receiving 3-Point Protection, the conductor 

dismounted the lead locomotive and proceeded to walk west, between the two main tracks, on the 

north side of his standing train, to untie handbrakes. An approaching westbound freight train 

sounded the whistle for the conductor walking in the foul and the conductor ducked between two 

freight cars to clear the oncoming movement. The conductor then reemerged from his safe location 

foul of the adjacent main track. He was struck by the westbound train and died 42 hours later. 

FE-2008-19 6/8/2008 UP La Porte TX Yard Brakeman AGE: 47

A three person train crew was performing switching operations at an industrial location. The 

brakeman controlling movements by radio, instructed the engineer to back up four cars to a 

coupling. The engineer, watching in the side mirror of the locomotive, noticed the cars moving 

down curved track instead of the straight track to the coupling. The switch target as seen in the 

mirror indicated the switch was lined for the spur track, not the straight track. The engineer saw 

someone walk in front of the movement and it was determined later to be the brakeman, who was 

struck and killed by the erroneous movement. Cellular telephone records indicated the brakeman had

made or received several telephone calls, including a two-minute call during the time of the fatal 

shove over the misaligned switch. 
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Fatalities During The Second Hour of Duty

FE-2008-24 7/8/2008 BNSF Fridley MN Utility Employee AGE: 40

A Utility Man working on Track 11 was bleeding the air from cars to be humped. An RCL job, 

working on Track 10, prepared to shove 84 cars toward the “hump.” Following their shove to the 

“hump” the utility employee was found dead on track 10, having been run over by the shove 

movement. The Coroner’s report suggested suicide. 

FE-2008-37 11/15/2008 MRL Laurel MT Yard Brakeman AGE: 39

A three person crew, operating a local freight train, moved their locomotives to a make-up track. 

After a job briefing, the switchman proceeded to make sure the train was together and the air hoses 

were coupled. The switchman did not observe sixteen cars at the end of the train were not coupled. 

A few minutes later, he radioed he was going between to make an air hose. The Engineer said: “Set 

and centered.” A few minutes earlier, the Conductor was walking the head-end and found a gap. 

Without communicating with the Switchman, the Conductor instructed the Engineer to pull forward 

so that he could open knuckles and prepare for a reverse movement to a coupling. Apparently, when 

the train moved forward, the 16 cars at the rear of the train began to roll, just as the Switchman was

reaching in to connect an air hose. The 16 free-rolling cars struck the standing portion of the train 

and killed the Switchman. 

FE-2009-08 2/7/2009 BNSF Holbrook AZ Freight Conductor AGE: 43

A two person crew had boarded their train on main track two and the conductor began walking the 

train making an inspection. At that time another train approaching on main track one observed the 

conductor walking in the foul of main track one. The engineer on the approaching train switched the

headlight from dim to bright to alert the conductor on the ground. A van driver beside the track also

attempted to get the attention of the conductor without success. The train on main track two 

struck and killed the conductor.