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

SAFETY BULLETIN 

2023-06

SUBJECT: Employee Amputation – Flat Switching, Kicking Operations and Securement 

The Federal Railroad Administration (FRA) is investigating a switching accident that resulted in 

the amputation of a crew member’s leg. On September 1, 2023, a switching crew, comprised of a 

locomotive engineer and conductor, was preparing to service an industry. The crew lined their 

12-car train towards a storage track and “kicked” one empty hopper car onto that track. The track 

already had secured cars situated about 500 feet away from the location where the car was 

kicked. The crew then pulled out of the storage track to service the industry, and the conductor 

realigned the switch for the industry track to spot 3 of the remaining 11 cars. As the train started 

moving onto the industry track, the conductor riding point to protect the shove move noticed the 

empty hopper car they had previously "kicked" rolling back towards them. After instructing the 

engineer to stop the train, via radio, the conductor dismounted and rushed towards the hopper 

car. In his attempt to apply the car’s handbrake, the conductor fell in the gauge of the rail where 

the car ran over the lower part of his body, resulting in the amputation of his left leg and severe 

injury to the other. The conductor had less than 2 years of railroad experience. 

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

is aware of this recent accident. Although FRA’s investigation into this accident is ongoing, FRA 

reminds railroads of the importance of ensuring switching operations are conducted safely, 

including ensuring: 

1. Operating rules and protocols adequately address hazards associated with “kicking” cars; 

2. Employees receive adequate field training to enable them to recognize risks associated with 

improperly secured “kicked” cars and understand proper procedures for responding to a rolling 

car, mounting equipment, and applying handbrakes safely; and 

3. All employees are reminded of the importance of proper securement protocols for unattended 

equipment, highlighting the risks linked to unintended movements of unsecured equipment. 

FRA also reminds railroads of the recommendations made in FRA Safety Advisory 2013-03. In 

that Safety Advisory, FRA recommended that railroads: 

Evaluate locations where flat switching operations are conducted and identify those 

where the physical characteristics and the types of cars being switched heighten the 

possibility that cars will roll out toward the employees conducting such operations. 

After identifying such locations, FRA recommends that railroads adopt procedures 

requiring that cars be shoved into couplings rather than kicked during such 

operations to lessen the potential safety risks, particularly when employees have to 

go between equipment.

In that same Safety Advisory, FRA also recommended that consistent with SOFA 

Recommendation # 1, railroads discuss with their employees the “need to ensure that equipment 

not attached to [a] locomotive is stopped, and is secured with handbrakes when necessary, 

before employees go between rolling equipment.” 
Prepared by: The Federal Railroad Administration, Office of Railroad Safety

FRA requests that railroads review this Safety Bulletin with all employees. As FRA completes its 

investigation, it may take additional actions with respect to this accident.

FRA Safety Advisory 2013-03 is available on FRA’s website:

https://railroads.dot.gov/elibrary/kicking-cars-and-going-between-rolling-equipment-during-flatswitching-operations 

Issued: September 11, 2023 

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