RAIL SAFETY

Improved Human 

Capital Planning 

Could Address 

Emerging Safety 

Oversight Challenges

Report to Congressional Requesters

December 2013

GAO-14-85

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-85, a report to 

congressional requesters

December 2013

RAIL SAFETY

Improved Human Capital Planning Could Address 

Emerging Safety Oversight Challenges

Why GAO Did This Study

Railroad accidents pose significant 

safety risks to railroads, their 

employees, passengers, and the 

public. FRA oversees safety of the 

nation’s railroads. In light of three high 

profile accidents in 2012 involving 

fatalities or hazardous materials, GAO 

was asked to review FRA’s oversight 

processes and the challenges to

railroad safety. This report examines

(1) the overall framework that FRA, the 

states, and the railroads use to ensure 

rail safety; (2) the extent to which FRA 

and the railroads assess safety risks 

and allocate resources to address 

those risks; and (3) what challenges, if 

any, exist to FRA’s current safety

framework, and what ongoing and 

emerging issues FRA faces. GAO 

analyzed FRA accident and incident 

data, reviewed the analytical models 

FRA uses to incorporate risk into its 

inspection program, and interviewed 

FRA headquarters and field safety 

staff, officials from the 7 largest freight 

railroads and 11 smaller railroads, 

industry associations and 7 rail labor 

organizations.

What GAO Recommends

GAO recommends that FRA develop

(1) a plan for finalizing its rulemaking 

and interim steps to implement its 

oversight of safety risk reduction 

programs, and (2) a strategic human 

capital plan that identifies and 

prioritizes FRA’s human capital needs, 

links them to FRA’s strategic goals and 

objectives, and includes approaches 

for how FRA will recruit, train, and 

retain inspectors and its new workforce 

of PTC and safety risk management 

specialists. DOT agreed to consider 

the recommendations and provided 

technical and other comments, which 

were incorporated as appropriate. 

What GAO Found

The Federal Railroad Administration’s (FRA) rail-safety oversight framework 

relies on inspections to ensure railroads comply with federal safety regulations. 

FRA inspects railroad infrastructure and operations, identifies safety defects, and 

may, if warranted, cite the railroads for violations of federal safety regulations.

The agency estimates that its inspectors have the ability to annually inspect less 

than 1 percent of the railroad activities covered in regulation. As a result, 

railroads have the primary responsibility for safety of the railroad system. To 

formulate regulations, FRA instituted the Railroad Safety Advisory Committee, a 

forum for FRA, the railroads, rail labor organizations, and other stakeholders to 

arrive at a consensus on proposed rules. Thirty states partner with FRA in 

providing FRA-certified railroad safety inspectors who are also authorized to 

enforce federal safety regulations. Finally, many railroads have additional safety 

programs, rules, and technologies to ensure safety beyond the required federal 

standards. 

FRA has developed a risk-based approach to direct its inspection efforts, but the 

agency has been slow to implement broader risk reduction planning. FRA has 

two tools to help direct its inspection efforts—the National Inspection Plan (NIP) 

and the Staffing Allocation Model (SAM). The NIP process uses past accident 

and other data to target FRA’s inspection activities, and the SAM estimates the 

best allocation of the different types of inspectors across FRA regions in order to 

minimize damage and casualties from rail accidents. However, all eight FRA 

regional administrators expressed concerns about FRA’s staffing process that 

relies primarily on the SAM to predict appropriate regional inspector needs, and 

that does not allow the flexibility needed to accommodate the regions’ changing 

resource needs. In addition, the Railroad Safety Improvement Act of 2008

mandated safety risk reduction plans primarily for large freight and passenger 

railroads. FRA has not yet issued the final rule directing railroads to develop the 

plans, which was mandated to be issued by October 2012. According to FRA, the 

rulemaking was delayed due to concerns by railroads over their potential liability. 

Although FRA anticipates completing approval of railroad’s plans by 2016, the 

agency has not developed an interim plan with specific timeframes to ensure that

there are no further delays in issuing regulations and that timely evaluation and 

approval of the railroads’ risk reduction plans occurs.

FRA faces several rail safety challenges, including how it will: (1) implement its 

oversight of positive train control (PTC), a technology designed to prevent certain 

types of rail accidents caused by human factors, and risk reduction plans; (2) 

adjust to changing rail traffic flows; and (3) ensure it has enough inspectors for its 

current and future oversight workload, as FRA expects 30 percent of field safety 

staff will be eligible to retire in 5 years. While FRA has long-term rail safety goals, 

its ability to meet those goals and respond to challenges is hampered by its lack 

of a strategic human capital plan. FRA officials stated that due to uncertainties 

about their budget, PTC implementation, and risk reduction plans, they plan for 

human capital needs in their annual budget request, rather than through a 

strategic human capital plan. However, without a plan, FRA may not make wellinformed decisions about its workforce needs including having inspectors with 

the right skills for its current oversight activities and enough specialists to 

oversee the rail industry’s implementation of PTC and safety risk reduction plans.

View GAO-14-85. For more information, 

contact Susan Fleming at (202) 512-2834 or 

flemings@gao.gov.
Page i GAO-14-85 Rail Safety

Letter 1 

Background 4

FRA’s Rail-Safety Oversight Framework Relies on ComplianceBased Inspections 9

FRA Uses A Risk-Based Approach to Direct Inspections, but Has 

Been Slow to Implement Broader Risk Reduction Planning 17

FRA Faces Challenges to Rail Safety Oversight, and Lack of a 

Strategic Human Capital Plan Hampers Its Ability to Respond to 

These Challenges 24

Conclusions 35

Recommendations for Executive Action 36

Agency Comments 36

Appendix I Objectives, Scope, and Methodology 38

Appendix II GAO Contact and Staff Acknowledgments 43

Table

Table 1: Federal Railroad Administration’s Inspection Disciplines 

and Total Number of FRA Inspectors, as of April 2013 10

Figures

Figure 1: Train Accident Rate per Million Train Miles, 1980–2012 6

Figure 2: Train Accidents by Primary Cause, 2003–2012 7

Figure 3: Trespasser and Highway-Rail Grade Crossing Fatalities, 

2003–2012 8

Figure 4: An Inoperable Bent Hand Brake Wheel 11

Figure 5: Examples of the Effects of Adverse Weather on Railroad 

Track 28

Contents 
Page ii GAO-14-85 Rail Safety

Abbreviations

AAR Association of American Railroads

ASLRRA American Short Line and Regional Railroad Association

C3RS Confidential Close Call Reporting System

DOT Department of Transportation

FAA Federal Aviation Administration

FHWA Federal Highway Administration

FRA Federal Railroad Administration

FTE full-time equivalent

NIP National Inspection Plan

PHMSA Pipeline and Hazardous Materials Safety Administration

PTC Positive Train Control

RAIRS Railroad Accident and Incident Reporting System

RRP Risk Reduction Program

RSAC Railroad Safety Advisory Committee

RSIA Rail Safety Improvement Act of 2008

SAM Staffing Allocation Model

SMS Safety Management Systems

SOFA Switching Operations Fatality Analysis

SSP System Safety Plan

TTC Transportation Technology Center

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Page 1 GAO-14-85 Rail Safety

441 G St. N.W.

Washington, DC 20548

December 9, 2013

The Honorable John D. Rockefeller IV

Chairman

Committee on Commerce, Science, and Transportation

United States Senate

The Honorable Richard Durbin

United States Senate

Railroad accidents pose significant safety risk to railroads, their 

employees, passengers, and the public. In July 2013, approximately 20 

miles from the United States border in Lac-Mégantic, Canada, a runaway 

freight train derailed and exploded, killing 47 people and destroying the 

center of the town. This and other recent accidents demonstrate the type 

of destruction that train accidents can cause. The safety record of the 

railroad industry in the United States has shown marked improvement in 

the last 20 years, and according to Federal Railroad Administration (FRA) 

data, 2012 was the safest year on record; nonetheless, recent train 

accidents continue to underscore the need for vigilance. FRA provides 

regulatory oversight of the safety of about 780 United States railroads 

operating on about 200,000 miles of track, including both the issuing and 

enforcing of safety regulations.

The most recent authorization of FRA’s rail safety activities occurred in 

2008 through the Rail Safety Improvement Act of 2008 (RSIA).1 FRA is 

responsible for implementing certain provisions of RSIA, which was due 

to be reauthorized at the end of fiscal year 2013.2 RSIA gave FRA new 

responsibilities, including the oversight of the implementation of positive 

train control (PTC)3 and railroad safety risk reduction programs. Since the 

 

1

Pub. L. No. 110-432, div. A, 122 Stat. 4848 (Oct. 16, 2008). 

2

As of December 6, 2013, the RSIA had not been reauthorized.

3

PTC is a system of integrated technologies capable of preventing collisions, over-speed 

derailments and unintended train movements. Although railroads are developing and 

implementing slightly different PTC systems, such systems require active train location 

detection and tracking capabilities, computer networking technologies, software that 

accurately calculates braking distances for different types of trains, and a reliable wireless 

communication network to link all of these operating elements and system components.

 
 

Page 2 GAO-14-85 Rail Safety

enactment of RSIA, FRA has had to manage these new responsibilities, 

in addition to its regular oversight activities, in an increasingly austere 

budget environment.

In light of the three high-profile rail accidents in 2012 including fatal 

accidents in Maryland and Illinois, and a hazardous materials accident 

involving an explosion and fire in Ohio, you asked us to review FRA’s 

railroad safety oversight and emerging rail-safety issues. This report 

discusses (1) the overall framework that FRA, the states, and the 

railroads use to ensure safety of rail operations and infrastructure, (2) the 

extent that FRA and the railroads assess safety risks and allocate 

resources to address those risks, and (3) the challenges to the framework 

and the ongoing and emerging issues FRA faces in railroad-safety 

oversight.

To determine the overall railroad-safety framework that FRA, the states, 

and the railroads use to ensure the safety of railroad operations and 

infrastructure, we examined applicable laws and regulations, FRA 

guidance, and other documentation, including reports describing the 

oversight mechanisms that FRA uses to ensure railroad safety.4 We 

interviewed FRA headquarters and regional officials, state railroad-safety 

program officials and railroad officials to understand railroad safety 

programs, how inspections are conducted, and the extent to which 

federal, state, and industry representatives coordinate with each other to 

oversee railroad safety. We conducted site visits to three of FRA’s eight 

regions: Atlanta, Georgia (Region 3); Chicago, Illinois (Region 4); and 

Fort Worth, Texas (Region 5). These three regions together accounted for 

over 50 percent of all train accidents that occurred from 2003 through 

2012. We selected these regions using criteria which included the number 

 

4

GAO, Rail Safety: The Federal Railroad Administration Is Taking Steps to Better Target 

Its Oversight, but Assessment of Results Is Needed to Determine Impact, GAO-07-149

(Washington, D.C.: Jan. 26, 2007); Rail Safety: The Federal Railroad Administration Is 

Better Targeting Its Oversight, but Needs to Assess the Impact of Its Efforts, GAO-07-390

(Washington, D.C.: Jan. 30, 2007); Rail Safety: The Federal Railroad Administration Is 

Better Targeting Safety Risks, but Needs to Assess Results to Determine the Impact of Its 

Efforts, GAO-07-841T (Washington, D.C.: May 22, 2007); Rail Safety: Preliminary 

Observations on Federal Rail Safety Oversight and Positive Train Control Implementation, 

GAO-13-679T (Washington, D.C.: June 19, 2013), and DOT, Office of Inspector General 

Audit Report: FRA Is Nearing Completion of Rules Required by the Rail Safety 

Improvement Act, but Needs to Improve Oversight, CR-2013-070 (Apr. 17, 2013).
 

Page 3 GAO-14-85 Rail Safety

and mix of Class I, II, and III railroads5 operating in the region, the highest 

number of reportable train accidents during the last 10 years by region 

including highway-rail grade crossing accidents, as determined by our 

analyses of FRA accident data, and the extent to which state safety 

inspectors operated in the region. We also selected a non-probability 

sample of 11 Class II and Class III railroads in four FRA regions to obtain 

their perspectives about federal and state railroad safety oversight. We 

selected railroads in these four regions (Regions 1, 3, 4, and 5) because 

they had the highest number of train accidents based on our analysis of 

FRA accident data. Our findings from our interviews in selected FRA 

regions, states, and railroads are not generalizable to all FRA regions, 

participating states,6 or across all Class II and III railroads.

To determine the extent to which FRA and the railroads assess safety 

risks and allocate resources to address those risks, we reviewed FRA 

documentation on the National Inspection Plan (NIP) process and the 

Staffing Allocation Model (SAM) and interviewed relevant FRA 

headquarters officials, all FRA regional administrators, and FRA safety 

specialists in Regions 3, 4, and 5 to discuss FRA’s inspection and staffing 

models, as well as other reports that track inspector activities and allocate 

resources based on risk. We used standard economic and statistical 

principles as criteria to assess the general reasonableness of the 

approach and assumptions used in the models. We also obtained 

information on the status of FRA’s implementation of its rulemaking 

regarding railroads’ risk reduction plans.7 We interviewed representatives 

from all seven Class I railroads and eight FRA regions about how they 

managed safety risks, allocated inspection and other resources based on 

risk, and responded to changes in safety risks. We interviewed officials at 

our 11 selected Class II and III railroads to understand their safety 

challenges and how they managed safety risks. We also interviewed 

representatives of seven rail labor organizations and industry 

associations to obtain their perspectives on these issues.

 

5

The Surface Transportation Board classifies freight railroads based on annual revenues. 

As of 2011 (the last year of data available), Class I freight railroads are those railroads 

that earn more than $433 million annually, Class II earn from about $35 million to $432 

million annually and Class III railroads earn less than about $35 million annually.

6

States may participate in a cooperative railroad safety program with FRA. 

7

Pub. L. No. 110-432, div. A, § 103.
 

Page 4 GAO-14-85 Rail Safety

To identify challenges in safety oversight and emerging issues that FRA 

and the railroads face, we interviewed FRA headquarters officials about 

changes in safety risks and FRA’s plans to respond to those changes. We 

interviewed all FRA regional administrators and FRA Region 3, 4, and 5 

safety specialists. We interviewed state rail-safety program managers in 

California, Florida, Illinois, and Texas and representatives from all seven 

Class I railroads, selected Class II and III railroads, and seven rail labor 

organizations about emerging and ongoing safety issues. Finally, we 

interviewed FRA headquarters officials and obtained documentation on 

their initiatives to meet current and expected human capital requirements. 

Appendix I contains a more detailed explanation of our objectives, scope, 

and methodology.

We conducted this performance audit from December 2012 to November 

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

The United States railroad system consists of a vast network of 

operations that includes over 780 railroads with more than 230,000 

employees and 200,000 miles of track in operation. The freight railroad 

industry is dominated by the seven largest freight railroads, referred to as 

Class I railroads, which collectively operate over 1.7 trillion ton-miles and 

accounted for more than 90 percent of annual railroad-freight revenues in 

2012. There are also 10 Class II freight railroads that typically operate 

over 350 to 900 miles per railroad, and about 750 smaller Class III freight 

railroads with less than 350 miles of track that typically perform point to 

point service over short distances. In addition, Amtrak and 29 commuter 

railroads collectively carry an average of about 670 million passengers a 

year over 23 billion miles.

FRA provides regulatory oversight of the safety of United States railroads, 

both passenger and freight. FRA issues and enforces numerous safety 

regulations including requirements governing track, signal and train 

control systems, highway-rail grade crossing warning systems, 

mechanical equipment including locomotives and cars, and railroadBackground 
 

Page 5 GAO-14-85 Rail Safety

operating practices. FRA also enforces regulations related to the safe 

transportation of hazardous materials by rail.8

RSIA overhauled federal rail safety requirements by directing FRA to, 

among other things, develop additional new rail safety regulations and 

guidance in areas such as railroad risk reduction plans and highway-rail 

grade crossing safety. RSIA authorized an additional 200 positions for 

FRA during fiscal years 2009 through 2013, to meet these new 

responsibilities, but federal budget constraints have prevented FRA from 

filling these positions. In addition, from 2008 to 2010, FRA’s 

responsibilities grew from its primary focus of improving safety to a 

broader portfolio of safety and railroad project development activities. The

American Recovery and Reinvestment Act of 2009, and subsequent 

appropriation acts have provided more than $10 billion for rail corridor 

improvement, development, and planning grants.

The overall trend in rail accidents has been positive over the last 30 

years. Rail accident rates declined dramatically from 1980 to 1987, and 

then fluctuated around four accidents per million train miles from 1992 to 

2003.9 However, there has been a clear positive trend in recent years, 

with the rate declining about 50 percent between 2004 and 2012. As a 

result, according to FRA officials and FRA data, 2012 was the safest year 

on record (see fig. 1).

 

8

Hazardous materials regulations are issued by the Pipeline and Hazardous Materials 

Safety Administration (PHMSA).

9

FRA reports the railroad accident rate as the number of accidents that cause a certain 

amount of property damage or injuries or fatalities to railroad workers or passengers per 

million train miles.
 

Page 6 GAO-14-85 Rail Safety

Figure 1: Train Accident Rate per Million Train Miles, 1980–2012

Railroads are required to report the causes and other information 

regarding all reportable rail accidents to the FRA.10 FRA classifies the 

causes of train accidents into five categories: train operations – human 

factors; track, roadbed and structures; signal and communication; 

mechanical and electrical failures; and miscellaneous causes. According 

to FRA data, track and human factors causes accounted for more than 70 

percent of all the 25,342 reported railroad accidents from 2003 to 2012 

(see fig. 2). Those accidents caused by human factors result from actions 

such as improperly positioning track switches, moving train engines or rail 

cars without proper authority, leaving rail cars in a position that obstructs 

the track, or failing to secure a sufficient number of handbrakes. 

Accidents caused by defective track result from such things as defective 

 

10A train accident is any collision, derailment, fire, explosion, act of God, or other event 

involving operation of railroad on-track equipment (standing or moving) that results in 

reportable damages greater than the current reporting threshold to railroad on-track 

equipment, signals, track, track structures, and roadbed. 49 C.F.R. §225.5. The threshold 

for reportable train accidents in 2013 was $9,900. FRA does not include highway-rail 

grade crossing or trespasser accidents that do not meet this property damage threshold or 

result in a rail worker’s injury or fatality.
 

Page 7 GAO-14-85 Rail Safety

or ineffective crossties; broken or worn switch points; or broken, fissured 

or fractured rail components.

Figure 2: Train Accidents by Primary Cause, 2003–2012

Note: The miscellaneous causes category contains numerous causes such as environmental 

conditions, loading procedures, and unusual operating conditions, among others.

According to railroad and other stakeholders, a number of factors have 

contributed to improvements in rail safety including: improved financial 

health of railroads, investments in railroad infrastructure, and adoption of 

new safety regulations or safety-related technologies. Even with the 

significant reduction in accident rates, however, from 2003 to 2012, an 

average of 10 people were killed and 300 people were injured in train 

accidents annually.11

In addition to FRA-reportable train accidents, highway-rail grade crossing 

accidents and trespasser incidents constitute a majority of all fatalities 

associated with the railroad industry. In 2012, there were 271 fatalities at 

highway-rail grade crossings in the United States, and 554 trespasser 

fatalities (see fig. 3). While there has been some decline in the number of 

highway-rail grade crossing fatalities over the past 10 years, reducing the 

 

11These figures do not include highway-rail grade crossing or trespasser fatalities.
 

Page 8 GAO-14-85 Rail Safety

number of trespasser fatalities has been more difficult. Improving this 

aspect of safety is complicated by the fact that the amount of railroad 

right-of-way and number of highway-rail grade railroad crossings in the 

United States is very large. As of the end of 2012, FRA’s national 

inventory identified 210,621 public and private highway-rail grade 

crossings. Reducing highway-rail crossing and trespasser fatalities is 

difficult because a train cannot swerve or easily stop to prevent collisions. 

According to FRA officials, the average freight train is about one to oneand-a-quarter miles in length and at 55 miles per hour it can take a mile 

or more to come to a stop after the locomotive engineer applies the 

emergency brake.

Figure 3: Trespasser and Highway-Rail Grade Crossing Fatalities, 2003–2012
 

Page 9 GAO-14-85 Rail Safety

FRA conducts inspections to ensure railroads’ compliance with federal 

safety regulations. Thirty states also partner with FRA in providing FRAcertified state railroad-safety inspectors, who have been delegated 

authority to enforce federal safety regulations. Many railroads have 

additional safety programs, rules, and technologies beyond the required 

federal standards.

FRA is a small agency with limited resources available to execute the 

large scope of its oversight responsibility especially compared to the size 

of the industry it regulates. By FRA’s own estimation, its inspectors have 

the ability to inspect less than 1 percent of the federally-regulated railroad 

system. Therefore, railroads have the primary responsibility for safety, 

and FRA relies on a number of strategies to achieve the maximum 

possible oversight of the system. These strategies include conducting 

inspections, enforcing compliance with regulations, issuing new 

regulations, and coordinating with industry to employ additional safety 

measures beyond the federal requirements, when possible.

FRA executes its regulatory and inspection responsibilities through a staff 

of railroad safety experts, inspectors, and other professionals.12 For 

example, to determine a railroad’s compliance with FRA regulations, 

inspectors examine track, equipment, signal devices, employee actions, 

and procedures and review maintenance and accident records. FRA also 

conducts focused inspections involving inspectors from a variety of 

disciplines or multiple inspectors from a single discipline, working together 

at a specific location or rail facility to target railroad issues that pose the 

greatest safety risk, based on inspection data, accident history, rail traffic 

density, and professional judgment.

As of fiscal year 2013, there were 347 FRA safety inspectors, in five 

safety disciplines, assigned to eight regional offices across the nation. 

These disciplines are track, signal and train control, motive power and 

equipment, operating practices, and hazardous materials. (See table 1.) 

 

12FRA requested 881.5 full-time equivalents (FTE) to fund FRA’s portfolio of rail safety 

and development programs in fiscal year 2014. The request included 22.5 additional FTE 

to support safety programs and help oversee the grant programs, which was an increase 

compared to prior fiscal year. Currently, FRA has 98 percent of its inspection positions 

filled.

FRA’s Rail-Safety 

Oversight Framework 

Relies on ComplianceBased Inspections

FRA Relies on Inspections 

to Ensure Railroads’

Compliance with Federal 

Safety Regulations
 

Page 10 GAO-14-85 Rail Safety

In addition, FRA’s regional offices include safety specialists and program 

managers for highway-rail grade crossing safety and trespass prevention.

Table 1: Federal Railroad Administration’s Inspection Disciplines and Total Number of FRA Inspectors, as of April 2013

Discipline Examples of what inspections cover (not all inclusive)

Inspector

Total

Track Condition of track and structures, including track components and geometry, railroad track 

inspections, and programs to maintain continuous welded rail track and protect roadway 

workers. (In addition to manual inspections, FRA has an automated track inspection 

program that uses data produced by vehicles that precisely measure track geometry.)

78

Signal and train control Signal switching systems, locomotive signal devices, locks and brake application, including 

related recordkeeping, testing, modifications, and repairs. 

59

Motive power and 

equipment

Design and operation of railroad rolling equipment, including railroad freight and passenger 

car safety, locomotive safety and maintenance, safety devices, brake system safety, and 

emergency preparedness procedures.

81

Operating practices Railroad operations related to human factors, including employee compliance with railroad 

operating rules, railroads’ monitoring of this compliance, drug and alcohol testing of 

employees, employees’ hours of service, radio communications, locomotive engineer 

qualification, and accident and incident reporting. 

79

Hazardous materialsa Rail transportation of hazardous materials, including the integrity, markings, maintenance, 

and placement of tank cars, the training of train crews, security, and emergency 

preparedness.

50

Total 347

Source: GAO Analysis of FRA Information.

Note: There is a total of 664 FRA safety staff located at FRA headquarters and regional offices; 173 

are located in headquarters and 491 in the field. This FRA safety staff total includes the 347 railroad 

safety inspector positions, as well as specialists, engineers, economists, administrative, and other 

positions. As of April 2013, 23 of these 347 positions were vacant. Additionally, about 30 percent of 

FRA safety field employees will be eligible to retire in the next 5 years.

a

FRA enforces regulations issued by the Pipeline Safety and Hazardous Materials Safety 

Administration (PHMSA) for hazardous materials.

Railroads are required to comply with the safety standards set in federal 

safety regulations. When railroads do not comply or identified defects are 

serious, FRA may cite violations and assess civil penalties, either against 

railroads or individuals. Thus, FRA’s approach is compliance-oriented and 

does not holistically assess safety problems across a railroad’s system. 

On average, FRA collected about $15.4 million per year in civil penalty 

final assessments or settlements between fiscal years 2009 through 

2012. Although FRA uses civil penalties as its primary enforcement tool, 

under its authority, it can also take other enforcement actions. For 

example, FRA can issue warnings, special notices for repair, compliance 
 

Page 11 GAO-14-85 Rail Safety

and emergency orders and disqualification orders.13 For example, in 

2012, to remove an imminent and unacceptable threat to public safety, 

FRA issued an emergency order to prevent operation of trains over a 

highway-rail grade crossing until the railroad restored the active warning 

devices to proper working order. Figure 4 shows a serious defect 

identified by an FRA motive power and equipment safety inspector while 

conducting an inspection prior to a train departure. A broken safety 

appliance such as the inoperable hand brake wheel can result in the 

inability to properly secure a train during an emergency and can result in 

the injury or death of a railroad employee. This defect resulted in a 

citation because the condition did not meet the federal railroad safety 

appliance standard.

Figure 4: An Inoperable Bent Hand Brake Wheel

 

13Most of the FRA regulatory authority is codified under 49 C.F.R. pts. 200 to 244. 
 

Page 12 GAO-14-85 Rail Safety

In 1996, FRA implemented a collaborative approach to developing and 

issuing rail safety rules and regulations by creating the Railroad Safety 

Advisory Committee (RSAC). The RSAC includes stakeholders in the rail 

community such as government entities, railroads, rail labor 

organizations, trade associations, suppliers, and others that work with

FRA to develop solutions to railroad safety and regulatory issues. FRA 

develops and issues rail safety rules and regulations while involving 

RSAC members in the rulemaking process. The RSAC recommendations 

are advisory, and FRA may deviate from them, if it so chooses. Recent 

RSAC-supported rulemakings have addressed passenger rail hours of 

service, conductor certification, locomotive safety standards, and positive 

train control. Achieving consensus from the stakeholders can be 

challenging and time-intensive; however, six Class I railroads, one rail 

labor organization, and one other rail-safety stakeholder we interviewed 

told us they believe this process is an improvement over FRA’s prior 

approach, which did not include them in the process before issuing a 

notice of proposed rulemaking. In addition, they noted that in general, the 

RSAC partnership has improved the quality of railroad safety initiatives 

and fostered a greater level of compliance with safety regulations.

Even with the RSAC process, new technologies pose a challenge to FRA 

regulations. In 2008, FRA noted that its regulations cannot keep up with 

the rapid pace of technological change, citing, for example, the 8 years it 

took to put one new technology signal and train control regulation in 

place. According to railroad officials, FRA is not always able to quickly 

adapt and respond to new railroad technologies. This situation affects the 

FRA inspectors’ ability to maintain oversight. For example, two Class I 

railroad officials we spoke with said that technological improvements such 

as automated sensors that measure physical attributes or thermal output 

on trains can be more comprehensive and identify defects that visual 

inspections cannot. In contrast, officials from two rail labor organizations 

we spoke with stated that technological advances, such as the use of 

automated sensors, should supplement or enhance inspection 

capabilities and not replace physical inspections.

FRA supplements oversight of Class I railroads through the Railroad 

System Oversight program, established in October 2005. In addition to 

addressing safety compliance issues, this program addresses safety 

issues not subject to regulation, such as aspects of worker fatigue. Under 

this program, the agency assigns an FRA manager to work with each 

Class I railroad on identifying and resolving safety issues. According to 

FRA officials, these managers analyze accident and inspection data for 

their assigned railroad, and support FRA’s inspection and enforcement 
 

Page 13 GAO-14-85 Rail Safety

efforts. Under this program, FRA has begun annual meetings with the 

leadership of each Class I railroad to discuss its safety performance. 

Officials from two Class I railroads we interviewed said that their 

participation in this oversight program has enhanced their ability to ensure 

safety. 

In addition to the FRA oversight initiatives mentioned above, there are 

other FRA initiatives that contribute to the overall safety framework. Some 

of these other initiatives include partnering with organizations to increase 

safety awareness; coordinating efforts on research and development to 

test and evaluate the safety of locomotives, vehicles, track components, 

and signaling devices; and offering training to Class II and III railroads to 

ensure they are informed of changes in regulations and that railroad 

safety and any other concerns are being addressed. For example, FRA, 

in collaboration with the Association of American Railroads (AAR) 

operates the Transportation Technology Center (TTC) located in Pueblo, 

Colorado. The TTC is a 52-square mile test center that enables isolated 

testing and evaluation of freight and passenger rolling stock, vehicle and 

track components, and safety and signaling devices at a array of 

specialized laboratories and on 48 miles of high-speed railroad track. 

According to AAR officials, all classes of railroads have access to utilize 

the testing and evaluation center and can benefit from the resulting 

technological improvements made to safety. Also, the American Short 

Line and Regional Railroad Association (ASLRRA), in conjunction with 

FRA, offers numerous training seminars to Class II and Class III railroad 

employees to increase their knowledge of important aspects of railroad 

operations, including recent federal regulatory changes and oversight 

issues specific to the five railroad safety disciplines.

Thirty states have rail safety programs that partner with FRA to augment 

and support the national railroad safety effort. Under the current program, 

each participating state enters into an agreement with FRA to provide 

enhanced investigative and surveillance capability.14 Under this program 

FRA delegates oversight and enforcement authority to these state 

inspectors, who are recruited and trained in disciplines that align with the 

 

14The FRA State Rail Safety Participation Program is a voluntary state safety-inspection 

program that allows states to enter into an agreement with FRA in which state railroad 

safety inspectors are delegated authority to enforce federal regulations. 49 C.F.R. §§ 

212.101 - 212.115.

State Inspectors Augment 

FRA’s Oversight, but 

Inspection Coverage and 

Coordination Vary 
 

Page 14 GAO-14-85 Rail Safety

FRA’s inspection disciplines and are required to pass mandatory FRA 

training before they can be FRA-certified as qualified to perform 

inspections. Inspectors who participate in this program submit inspection 

reports to FRA and enforce federal rail-safety regulations. State 

participation in this voluntary program varies and, according to FRA data, 

there are about 170 state inspectors in all. More than half of all state 

inspectors are concentrated in six states: California, Illinois, Ohio, 

Pennsylvania, Texas, and West Virginia. In contrast, twelve participating 

states have small programs with only one or two inspectors, and 20 

states do not have any inspectors. California has the largest state 

program, with 35 inspectors in all five federal rail-safety inspection 

disciplines.

According to FRA region and state program officials we interviewed, the 

level of coordination between federal and state inspectors varies from 

state to state. Inspectors may divide up territories to ensure more 

inspection coverage to maximize their limited resources. For example, in 

one state, state track and structure inspectors take primary responsibility 

for part of the state, allowing FRA track and structure inspectors the 

flexibility to be deployed in another part of the state. In other states, the 

federal and state inspectors may cover the same territory and conduct 

inspections simultaneously, with or without advance coordination. FRA 

and state inspectors may also collaborate on joint or focused inspections. 

On the other hand, according to FRA regional and state officials, in some 

states coordination happens between individual state and federal 

inspectors in an informal manner. Representatives from five Class I 

railroads we spoke with said there appeared to be good coordination 

between the federal and state inspectors.

Railroads must adhere to all federal railroad regulations, which govern 

safety requirements, and applicable state railroad regulations in the states 

in which they conduct railroad operations. The railroads have primary 

responsibility for their own safe operation, and each performs its own 

safety activities including reviewing track inspection reports for accuracy, 

performing tests on electronic devices, understanding and utilizing 

automated test data, identifying and analyzing defective components, and 

identifying necessary corrective actions. Across all classes of railroads, 

most railroad officials said that they adopted a range of safety oversight 

approaches and technologies intended to provide additional assurance of 

safety beyond the required federal regulatory safety standards. Railroad 

officials we spoke with provided examples of various initiatives they have 

Railroads Also Conduct 

Inspections, and Many 

Have Safety Initiatives 

beyond Federal 

Regulations 
 

Page 15 GAO-14-85 Rail Safety

instituted and ways in which they address their self-identified safety risks. 

For example, Class I railroads have:

• Participated in the Switching Operations Fatality Analysis (SOFA) 

reporting. SOFA is a voluntary, non-regulatory, workplace-safety 

partnership with railroads, rail labor organizations, industry 

associations, and FRA. It was formed to look for commonalities 

among the fatalities that occur during switching operations and to 

develop findings and recommendations that will aid in preventing 

railroad employee deaths.

• Developed various policies, programs, incentives, and analyses to 

discourage unsafe behavior and encourage safe behavior through 

training, visual reminders of the importance of safety, and financial 

incentives for safe workplace habits. Also, five Class I railroads–as 

encouraged by a rail labor organization–conduct root-cause analyses 

to determine why and how an accident occurred, and what can be 

done to prevent similar accidents in the future across their rail 

systems. 

• Participated in or have operating practices similar to the Confidential 

Close Call Reporting System15 (C3RS), which allows railroad 

employees to report close call events or “near-misses.” This effort 

helps to identify safety trends within the rail network, learn about 

potentially unsafe conditions, and improve safety practices to avoid an 

accident or incident with more serious consequences.

• Focused on improving the way training procedures and practices are 

provided to railroad employees. Railroads have cited the use of 

locomotive simulation training machines that allow train crews to learn 

 

15C3RS is a risk reduction initiative that was designed to help adapt a confidential 

reporting system to the needs of the United States railroad industry and to evaluate its 

effectiveness in improving safety. Beginning in February 2007, FRA sponsored pilot 

projects on divisions of four railroads: Union Pacific Railroad, Canadian Pacific Railway, 

New Jersey Transit, and Amtrak (nine yard locations). FRA plans to expand the C3RS 

implementation by adding new railroads. Of the four railroads participating in the pilot 

projects, the Canadian Pacific Railway completed its agreed-upon 5-year test and elected 

not to continue. The Union Pacific Railroad requested to be allowed to continue beyond its 

5-year completion date and is making plans to add more sites. New Jersey Transit is 

preparing to include mechanical employees in its program, and Amtrak expanded the 

program across its system for operating practices employees and is considering adding 

mechanical employees to its program. 
 

Page 16 GAO-14-85 Rail Safety

and make mistakes without consequences, and test their skills to 

determine competency in realistic scenarios. This type of training 

helps railroad training officials and management understand where 

improvements can be made and areas to focus on training locomotive 

employees who operate on certain trains and along different routes.

• Incorporated new technologies and reinvested in infrastructure and 

equipment, which has enhanced safety by allowing railroads to be 

proactive in identifying various safety issues. Five Class I railroads 

have cited the importance of using “machine vision” technologies and 

wayside detection systems to identify undue stresses and potentially 

unsafe conditions on railroad tracks, wheels, and other railroad 

equipment.16 According to officials at one Class I railroad, the analysis 

of the detector information can supplement mechanical analysis to 

help determine when a train should be taken out of service for 

mechanical components that are not operating consistently or that are 

failing faster than others. Another Class I railroad cited the use of 

inward-facing locomotive cab cameras to identify electronic device 

distractions or issues that they would have not otherwise known 

needed to be addressed, such as engineers’ not wearing seatbelts.

In addition to the initiatives mentioned above, there are other activities 

that railroads, states and local entities, and safety organizations are 

involved with that also contribute to the overall safety framework. These 

other contributing initiatives include public education and outreach, 

enforcement, engineering, and evaluation. For example, Class I railroads 

have hosted an “Officer on A Train” event, in which participating railroads 

partner with local law enforcement to promote compliance with state 

motor-vehicle laws and penal codes on highway-rail grade crossings and 

rights-of-way. Also, state departments of transportation, local law 

enforcement, and railroads have partnered with Operation Lifesaver17 by 

 

16“Machine vision” consists of recording digital images and videos and using algorithms to 

detect certain attributes in these images which can provide greater objectivity and 

reliability as well as data archiving and trending capabilities for many track components. 

Wayside detection systems measure characteristics such as wheel and bearing 

temperature and wheel geometry as trains pass, to monitor for predictive maintenance 

and to help identify defects before derailments occur.

17Operation Lifesaver is a public-private partnership that promotes awareness to help 

save lives lost in highway-rail grade crossing collisions and from trespassing on railway 

property. It works with the rail industry, government, police, unions, many public 

organizations, and community groups.
 

Page 17 GAO-14-85 Rail Safety

providing presentations to schools, community organizations, driver’s 

education classes, as well as teaming up to provide education at 

weekend events such as festivals and safety fairs. Together these entities 

work to ensure that public education about the hazards surrounding 

railroad property and trains, implement railroad engineering initiatives to 

increase safety and reduce trespassing and injuries and deaths, and 

encourage police enforcement to discourage unsafe actions and ensure 

public safety around railroads.

Since 2006, FRA has developed a risk-based approach to help direct its 

inspection efforts, but FRA regional officials expressed concerns about 

how well its risk-based model appropriately balances inspector needs in 

their regions. RSIA mandated risk reduction plans for Class I, passenger 

(commuter and inter-city), and other railroads that FRA determined 

needed such plans based on safety performance. The development of 

this risk reduction approach to oversight is intended to augment FRA’s 

current inspection regime and is a significant departure from FRA’s 

traditional compliance-driven approach. However, FRA has not yet issued 

the final rule directing railroads to develop such plans, which, under RSIA, 

was to be issued by October 2012.

FRA has developed a risk-based approach to its inspection program 

using two quantitative tools to help direct its inspection efforts. First, in 

2006, FRA developed the National Inspection Plan (NIP) process to use 

safety risk information to help target limited inspection resources to areas 

of higher risk.18 There are three steps to the NIP: (1) a quantitative model 

produces an initial, baseline set of targets for inspections; (2) FRA 

regions discuss the baseline targets with headquarters and adjustments 

are made to the initial inspection targets; and (3) the NIP is updated midyear to adjust for unforeseen events that required the use of inspection 

resources, such as accident investigations or changing safety conditions.

 

18We previously reported that the NIP had allowed FRA to better target inspections based 

on risk, and was an improvement over its previous approach, which was less structured 

and consistent. GAO, Rail Safety: The Federal Railroad Administration Is Taking Steps to 

Better Target Its Oversight, but Assessment of Results Is Needed to Determine Impact, 

GAO-07-149, (Washington, D.C.: Jan. 26, 2007);

FRA Uses A RiskBased Approach to 

Direct Inspections, 

but Has Been Slow to 

Implement Broader 

Risk Reduction 

Planning 

FRA’s National Inspection 

Plan and Staffing 

Allocation Model 

Incorporate an Assessment 

of Risk
 

Page 18 GAO-14-85 Rail Safety

The NIP’s quantitative model minimizes the predicted number and 

severity of railroad accidents given the number of available FRA 

inspectors in each FRA region. The quantitative model for making this 

estimation uses data including: (1) the most recent 3 years of accident 

data from reports that railroads are required to file about accidents that 

occur on their tracks,19 (2) data from FRA and state inspection activity, 

and (3) information on railroad activities such as train miles and other 

data. The model uses these data to determine the scope of what FRA’s 

inspectors should inspect in a given year.20 The NIP model provides 

targets for the amount of inspection activity each FRA inspector should 

have at each railroad within each state. After the baseline inspection 

targets are established, FRA’s regional directors propose modifications to 

the inspection targets produced for each region, using their judgment and 

knowledge of which railroads or disciplines may require more FRA 

oversight than the NIP’s model indicates. As a result of these discussions, 

FRA headquarters and regions arrive at a modified set of inspection 

targets. All the FRA regional administrators told us that the flexibility in 

this process allows them to target inspection needs based on changing 

conditions in their regions.

FRA headquarters officials stated that the NIP model is not designed to 

account for newly emerging risks or react swiftly to recent accidents. 

Consequently, FRA allows for a mid-year correction of the NIP targets, 

based on input from FRA’s regional management. FRA regional 

administrators we spoke with indicated that this flexibility can help 

address new or emerging rail safety risks by deviating from the original 

NIP targets. For example, they stated that they sometimes re-allocate 

inspection targets to railroads that have had recent accidents, or because 

inspectors indicate a need for more oversight at a certain railroad based 

on assessments made during their regular inspection duties. Throughout 

the year, according to FRA regional administrators we spoke with, FRA 

headquarters and regional management monitor the inspection activities 

against the modified inspection baseline to determine if the inspection 

 

19Railroads are required to report monthly accident data and it may take 2 to 3 months for 

FRA to review the data and make it available for use in the NIP. FRA operating practices 

inspectors are responsible for reviewing railroad accident and incident records reporting, 

and may cite the railroads for violations leading to civil penalties for failing to adhere to 

reporting regulations. 

20The NIP model does not include highway-rail grade crossing and trespasser accidents in 

its analysis.
 

Page 19 GAO-14-85 Rail Safety

targets are being met. FRA’s regional administrators use the NIP to 

monitor and help manage the use of inspectors with “dashboard” reports 

that track progress in meeting plan targets. FRA regional administrators 

and supervisors said the dashboards are a good tool that gives them a 

quick review of their plan progress. Inspectors are expected to stay within 

2.5 percent of the NIP inspection targets and supervisors generally direct 

the activity of inspectors to meet the goals.

In addition to the NIP, FRA has also developed the Staffing Allocation 

Model (SAM), which is a planning and evaluation tool used to assess its 

inspection resources from a nationwide perspective. FRA uses the SAM 

to establish targets for the number of inspectors in four FRA inspection 

disciplines across all eight regions.21 In using the targets to help allocate 

and balance staff among disciplines and regions, FRA expects to 

minimize the resulting estimated costs of train accidents, including 

casualties. FRA uses the SAM results to determine where it may need to 

adjust the number of inspectors in a given region and discipline, given the 

resource constraints provided by the total number of inspector positions.

In 2007, the SAM model results indicated that there needed to be a 

change in the relative number of inspectors among the disciplines. FRA 

rebalanced its workforce using the SAM results, increasing the number of 

track inspectors and reducing the number of equipment inspectors. FRA 

officials stated that more recent SAM outputs have not indicated the need 

for major movements of inspectors between regions or disciplines. As of 

April 2013, no region and no inspection discipline within any region varied 

by more or less than two positions from the SAM model result; at that 

time FRA had 324 full-time inspectors and 23 vacant inspector positions. 

While FRA headquarters officials anticipate that there may be minor 

variations from SAM’s targets as a result of natural turnover of inspectors 

(e.g., retirements), they do not believe that these temporary variations will 

have long-term effects on FRA’s safety activities in the regions. However, 

FRA officials also stated that when the SAM calls for a change in the 

distribution of inspectors, they are somewhat limited in their ability to 

implement changes due to federal budget constraints. Adding new 

inspector positions in one region requires the rebalancing of inspector 

positions in another region.

 

21FRA hazardous materials inspectors are not allocated by the SAM because different 

factors determine the need for hazardous materials inspectors. 
 

Page 20 GAO-14-85 Rail Safety

Although FRA regional administrators we spoke with stated that the NIP 

process provides them with a good tool for planning for yearly inspection 

needs in their regions, all eight regional administrators told us that they 

see limitations in the process that FRA uses to determine staffing 

allocations. Further, all eight administrators noted that the staffing 

allocation model does not always reflect the appropriate inspection needs 

in their regions. FRA regional administrators can provide input to FRA 

headquarters on the model’s results based on their views of how many 

inspectors the region needs; however, the overall process for determining 

inspector resources across the regions was perceived by the 

administrators to be much less flexible than the NIP process. Specifically, 

several regional administrators told us that even though they have 

inquired about obtaining inspectors in a specific discipline to meet current 

safety inspection needs, they were generally unable to get additional 

inspectors because the staffing process is not flexible enough to meet 

these demands. They also expressed concern over the staffing pressures 

this can create, as they are forced to spread inspectors over larger 

territories, sometimes spanning several states.

FRA headquarters officials also told us that while the SAM model 

provides an initial basis for allocating staff, and has been refined based 

on what they have learned from making improvements to the NIP model, 

the SAM is not designed to take into account certain changes. For 

example, it does not quickly reflect increasing freight train volume or 

increasing accidents in a particular region because the SAM uses past 

accident data to provide a baseline for the nationwide distribution of its 

inspectors. Over time, changes in accident data will be reflected in the 

model, but this will be evident some time after the change has occurred. 

While the SAM model allows FRA to account for some risks, it is not 

designed to anticipate quickly changing circumstances that may affect 

risk such as changes in the type or amount of freight traffic in a region. 

FRA officials stated that they handle those types of changes to inspector 

needs on an as-needed basis through temporary detail assignment of 

FRA inspectors from other regions or headquarters.

FRA’s ability to quickly adjust to changing conditions also is affected by 

the fact that hiring and staffing decisions are long-term decisions, and 

filling a gap in staffing with a qualified person can take years. According 

to FRA officials, it can take 1 to 2 years to find, hire, train, and certify a 

new inspector with previous railroad experience, and 3 to 4 years to 

certify an inexperienced trainee. For example, in one case, an FRA 

regional administrator stated that when the staffing decisions did not 

provide for a replacement for a certain discipline, he covered that 

Regional Officials Have 

Concerns about FRA’s 

Process to Allocate Staff 
 

Page 21 GAO-14-85 Rail Safety

inspection load with inspectors from other states for 3 years until a 

replacement could be approved, hired, trained, and qualified.

FRA was required to issue a rulemaking for railroads’ development of risk 

reduction plans within 4 years of RSIA’s enactment. Although FRA issued 

an Advance Notice of Proposed Rulemaking and a Notice of Public 

Hearings, the agency has been slow to issue final regulations for the 

railroads to follow in developing the plans, and FRA missed the October 

2012 deadline for requiring certain railroads to develop and implement 

risk reduction plans. RSIA mandated that all Class I railroads, passenger 

railroads, and any railroad that FRA determines has inadequate safety 

performance develop a risk reduction plan and have it approved by 

FRA.22 The risk reduction concept is a comprehensive, system-oriented 

approach to safety that first determines an operation’s level of risk by 

identifying and analyzing applicable hazards and then develops plans to 

mitigate that risk. The objective is to identify and mitigate those risks 

proactively, with the intent of reducing or eliminating risks before an 

accident, injury, or fatality occurs. Railroad and rail-labor officials we 

interviewed said the risk reduction approach has the potential to improve 

safety because it provides the opportunity to identify the root cause of 

safety problems across a railroad’s system. As required by law, each 

railroad’s Risk Reduction Program Plan must include a risk-based hazard 

analysis, a Technology Implementation Plan and a Fatigue Management 

Plan.23

According to FRA officials, a significant factor in the delay resulted from 

the railroads’ concerns about access to information contained in the plans 

that could affect railroad liability. In particular, railroads expressed 

concern that risks identified in the plans would leave them exposed to 

legal liability in the case of an accident.24 FRA chose to split the risk 

 

22Railroads required to submit risk reduction plans account for most United States rail 

activity, but many non-Class I freight railroads will not be required to submit risk reduction 

plans; they may, however, opt to develop such plans.

23Pub. L. No. 100-432, div. A, § 103.

24Risk Reduction plans submitted to FRA, as required by RSIA, are not subject to the 

Freedom of Information Act. Additionally, FRA may prohibit the public disclosure of risk 

analyses or risk mitigation analyses it has obtained if the Secretary of Transportation 

determines that the prohibition of public disclosure is necessary to promote railroad safety.

49 U.S.C. § 20118.

FRA Has Missed the 

Mandated Deadline to 

Implement a 

Comprehensive Risk 

Reduction Approach
 

Page 22 GAO-14-85 Rail Safety

reduction plan process for freight and passenger railroads, and 

passenger-railroad guidance has progressed further than freight-railroad 

guidance. Under this split approach, passenger railroads will be required 

to have a System Safety Plan (SSP), a comprehensive process for the 

application of engineering and management principles, criteria, and 

techniques to optimize safety that might require a railroad to manage risk 

and to develop proactive hazard management methods that would 

support safety improvement. FRA expects to issue the final rule for the 

SSPs in early 2014.25 In addition, agency officials told us that they 

continue to work through their RSAC process to develop guidance and 

FRA anticipates issuing a final rule for the freight railroads’ Risk 

Reduction Program plans in early 2015 and expects that the railroads will 

have approved risk reduction plans in place by 2016.26 Implementing such 

an approach will likely take several years particularly given that FRA 

estimates that it will not complete the approval of railroads’ plans until 

2016. This delay continues to prevent FRA from implementing proactive 

oversight to help mitigate safety risks through risk management plans.

The Department of Transportation’s Inspector General has also reported 

on delays in FRA’s rulemaking related to a number of RSIA’s mandates. It 

recommended that FRA develop a plan for completion of outstanding 

RSIA-related rulemakings, including milestones for completion and a 

description of FRA’s rationale for prioritizing rulemakings. However, FRA 

only partially concurred with this recommendation.27 During our review, 

the agency had not yet developed an interim plan with specific time 

frames to direct and manage the implementation of the risk reduction 

program to prevent further delays. Developing a report that outlines these 

time frames and the steps needed to implement the program could help 

ensure that FRA identifies risks associated with the start of the program 

 

25Amtrak is among the passenger railroads covered and Amtrak officials said they were 

confident they could meet the requirements of the SSP, as Amtrak has had a System 

Safety Program in place since August 2006 that should meet many of the requirements.

26According to FRA officials, both the passenger and freight rules could be issued earlier if 

the Office of Management and Budget deems the rules to be non-significant.

27The Inspector General did not find FRA’s response to its recommendation to be fully 

responsive, and still recommended that FRA report a strategy, including milestones for 

completing its rulemaking, to resolve the recommendation. Department of Transportation, 

Inspector General, FRA is Nearing Completion of Rules Required by the Rail Safety 

Improvement Act, But Needs to Improve Oversight, CR-2013-070 (Washington, D.C.: Apr. 

17, 2013).
 

Page 23 GAO-14-85 Rail Safety

and would allow FRA to better inform Congress and other stakeholders of 

its progress in implementing the risk reduction program.

This is particularly important in light of the fact that implementing the more 

comprehensive risk-based approach to safety is a significant procedural 

and cultural change for FRA and the railroad industry. One Class I 

railroad official we interviewed observed that when his railroad instituted a 

risk reduction approach, employees had to think differently, in “root 

cause” terms rather than individual safety defects, and it was a difficult 

cultural transition. The addition of a risk reduction approach to FRA 

oversight will likewise be a cultural shift. As we noted earlier, FRA’s 

current oversight framework is largely a compliance-based framework, 

focused on ensuring adherence to federal safety regulations—the safety 

standards a railroad must meet. While FRA will continue with its current 

compliance-based inspections, auditing a railroad’s comprehensive 

approach to safety across its operations, as a risk reduction plan requires, 

is a substantially different task.

Moreover, this is the first time that FRA has overseen risk management at 

the system level. Other agencies involved in transportation safety, 

including the Pipeline and Hazardous Materials Safety Administration 

(PHMSA) and the Federal Aviation Administration (FAA), have utilized 

risk management approaches, in addition to standard compliance-based 

inspections, to enforce their safety rules and regulations. For example, 

prior to 2003, PHMSA traditionally performed its oversight role using 

safety standards that all operators must meet. However, PHMSA’s gas 

integrity management program is designed to improve pipeline safety by 

supplementing standard safety requirements with risk-based 

management principles, including performance indicators to measure 

progress. To implement the gas integrity management program, PHMSA 

had to develop both specialized training for its safety inspectors and a 

workforce plan that identified the resources and expertise it needed. Our 

past review of this program concluded that the gas integrity management 

program enhanced pipeline safety.28 Similarly, FAA is currently 

undertaking a broader risk-management approach called Safety 

Management Systems (SMS). SMS is designed to address cultural and 

organizational problems that lead to safety hazards, identifying system-

 

28GAO, Natural Gas Pipeline Safety: Safety Integrity Management Benefits Public Safety, 

but Consistency of Performance Measures Should Be Improved, GAO-06-946

(Washington, D.C.: Sept. 8, 2006).
 

Page 24 GAO-14-85 Rail Safety

wide trends in aviation safety, and managing the hazards before they 

result in accidents.29 Our past review of FAA’s implementation of SMS 

noted that FAA needed to acquire skills not currently found in its 

workforce to implement this change.30

FRA anticipates that oversight of risk reduction plans will increase the 

agency’s workload and require the addition of a new safety discipline, as 

the task of reviewing and approving the plans is significantly different than 

conducting safety inspections in the five traditional disciplines. To review 

and approve the risk reduction plans, FRA has hired three staff with 

experience in this safety approach and requested funding to hire an 

additional 10 risk-management specialists in its fiscal year 2014 budget 

submission. FRA officials stated that these specialists will both review 

railroad risk reduction plans and audit, in a broader sense, plans, data 

and other performance indicators generally without requiring an onsite 

presence at a railroad. Risk-management specialists will need to be able 

to identify systemic issues such as a need for training, as well as 

understand specific technical problems, and to serve as leaders of teams 

that will include relevant discipline inspectors or specialists.

FRA faces several ongoing and emerging challenges to its rail-safety 

oversight framework. These challenges include how FRA will: respond to 

highway-rail grade crossing and trespasser fatalities; accommodate 

adverse weather conditions; adjust its resources to industry changes like 

increasing rail traffic flows; adapt to the new safety implications posed by 

technology changes in the railroad industry, such as Positive Train 

Control (PTC); implement its new comprehensive safety risk reduction 

program; and ensure it has enough inspectors to fulfill its current and 

future oversight workload. While FRA has developed long-term rail safety 

goals, FRA’s ability to meet those goals and to respond to these 

challenges is hampered by its lack of strategic human capital planning. A 

strategic human capital plan would help define how FRA will ensure that 

its workforce will have the skills and the resources to meet these 

 

29This proactive approach is needed because aviation accidents have become 

increasingly rare events and less information is available for reactive analysis of accident 

causes. 

30GAO, Aviation Safety: Additional FAA Efforts Could Enhance Safety Risk Management, 

GAO-12-898 (Washington, D.C.: Sept. 12, 2012).

FRA Faces Challenges 

to Rail Safety 

Oversight, and Lack 

of a Strategic Human 

Capital Plan Hampers 

Its Ability to Respond 

to These Challenges
 

Page 25 GAO-14-85 Rail Safety

challenges. Without a human capital plan, FRA may not have trained, 

qualified workforce of inspectors and specialists in place to carry out its 

current inspections or to oversee the railroad industry’s implementation of 

PTC or comprehensive safety risk reduction plans.

Highway-rail grade crossing collisions and trespasser fatalities are 

ongoing problems currently handled outside of FRA’s compliance-based 

rail-safety oversight framework. Addressing highway-rail grade crossing 

collisions involves a variety of railroad and non-railroad actors, such as 

state highway departments, local governments, and the general public. In 

addition, the Rail-Highway Crossing Program administered by the Federal 

Highway Administration (FHWA) grants funds for highway-rail crossing 

safety improvements.31 States determine what improvements need to be 

made at highway-rail grade crossings, and typically use the federal 

program to pay railroads to make the planned improvements. About 48 

percent of public highway-rail grade crossings are equipped with active 

warning devices, such as flashing lights and gates. Rail safety 

stakeholders such as railroad and FRA officials stated that the current 

level of funding is inadequate to address the magnitude of the problem; 

however, FHWA officials noted that the level of funding is high per fatality 

compared with other types of auto fatalities, which account for many more 

deaths per year.

According to rail safety advocates, educating the public, enforcing traffic 

laws, and developing engineering improvements at highway-rail grade 

crossings are the three key elements of improving highway-rail grade 

crossing safety. As such, FRA employs railroad highway-rail grade 

crossing managers in each region who work with local communities to try 

to resolve highway-rail grade crossing issues. These managers do not 

perform railroad inspections, but rather perform a wide range of tasks 

including interacting directly with elected officials and the public on the 

topic of highway-rail grade crossing safety, establishing “quiet zones”, 

 

3123 U.S.C. § 130. 

FRA Faces Several 

Ongoing Safety Challenges

Highway-rail Grade Crossing 

and Trespasser Fatalities 
 

Page 26 GAO-14-85 Rail Safety

and closing highway-rail grade crossings.32 Officials from FRA, the 

railroads, and Operation Lifesaver emphasized the importance of 

educating the public about highway-rail grade crossing safety and closing 

crossings wherever possible. The railroads have made progress in recent 

years in reducing the total number of highway-rail grade crossings, and 

railroads may provide funds to local communities if they close or 

consolidate highway-rail grade crossings. For example, one Class I 

railroad we interviewed cited a program through which it offers 

communities up to $10,000 if the community will close the highway-rail 

grade crossing. FRA regional and railroad officials noted how difficult it 

can be to get a community to close a highway-rail grade crossing due to 

the local residents’ interest in maintaining convenient access to the 

community or because closing a highway-rail grade crossing could 

increase the amount of time it takes for emergency response personnel to 

reach someone in need. As of 2012, there were 210,621 public and 

private at-grade crossings, about 36,000 fewer than in 2003.33

In addition to highway-rail grade crossing concerns, trespasser fatalities 

remain an on-going challenge for railroads. The rates of trespasser 

fatalities have seen little improvement in recent years. The sheer amount 

of railroad track throughout the United States makes preventing 

trespassers difficult to address, and railroad officials noted that 

trespassing cannot be easily predicted or controlled. In some cases these 

events are suicides, which are particularly difficult to control. Officials we 

interviewed at one railroad said they have tried posting suicide hotline 

information in potential hot spots in the hope that they might, at the last 

moment, help deter the victim.

While progress in the area of trespasser fatalities has been slow, some 

noteworthy efforts are being made. Amtrak officials said that they recently 

conducted a mapping analysis to try to determine trespasser hot spots, 

and in doing so discovered the worst problem locations; Amtrak now 

 

32A quiet zone is a segment of a rail line that contains one or more consecutive public 

highway-rail grade crossings at which locomotive horns are not routinely sounded. 49 

C.F.R. § 222.9.

33Highway-rail grade crossings may be removed from the inventory due to abandonments 

or closures, and new crossings may also be added to the inventory. FRA data does not 

identify exactly how many highway-rail grade crossings have been closed on active rail 

lines. An at-grade crossing refers to the general area where the roadway intersects with or 

crosses the railroad track. 
 

Page 27 GAO-14-85 Rail Safety

hopes to develop ways to address the problems in these places. In 

addition, the Volpe National Transportation Systems Center is conducting 

a study of trespasser problems in West Palm Beach, Florida.

Railroads also face a variety of ongoing adverse weather conditions that 

affect safety for railroad crews, passengers, and the communities they 

serve and run through. Extreme heat or cold, floods, tornadoes, wildfires 

and hurricanes can affect rail operations and infrastructure. For example, 

during periods of extreme heat, railroad tracks (especially newer 

“continuously-welded” railroad tracks) can expand out of alignment 

without warning causing train derailments.34 During periods of extreme 

cold, tracks may contract causing the rails to break as well. To counter 

these threats, FRA has certain regulations related to weather conditions, 

such as standards related to bridge safety and track safety, when adverse 

weather events such as fires, floods, and extreme heat conditions could 

affect the rail infrastructure. Railroads we spoke with have also 

established procedures for weather-related risks, including very specific 

operating practices to be followed during or prior to these adverse 

weather events. For example, railroads we interviewed commonly reduce 

speeds during periods of extreme heat or cold to avoid derailments due to 

track misalignment or broken rails (see fig. 5 below for examples of the 

effects of adverse weather on railroad track). FRA has worked with the 

railroad industry through the RSAC process to determine what measures 

need to be taken to prevent the effects of adverse weather on continuous 

welded rails.

 

34According to FRA, “continuously-welded” rail refers to the way in which rail is joined to 

form track. Continuous welded rails are welded together to form one uninterrupted rail that 

may be several miles long in contrast to jointed rail where sections of rail are bolted 

together about every 40 feet.

Adverse Weather Conditions 
 

Page 28 GAO-14-85 Rail Safety

Figure 5: Examples of the Effects of Adverse Weather on Railroad Track

FRA faces an emerging challenge in dealing with expected increases in 

freight rail traffic. FRA has estimated that the amount of freight shipped in 

the United States would increase by 1.1 billion tons (about 9 percent) 

across all modes from 2010 to 2020, with about 176 million tons of the 

increased amount shipped by rail.35 According to the Association of 

American Railroads, this includes the rapid increase in freight rail traffic 

related to energy production, both in the transport of materials such as 

sand for use in hydraulic fracturing and the shipment of crude oil from oil 

fields. For example, crude oil shipments by rail increased from 9,500 

carloads in 2009 to almost 234,000 carloads in 2012. These oil fields 

have rapidly developed in different areas across the country (such as 

North Dakota, west Texas, eastern Ohio, and western Pennsylvania). As 

 

35This assumes that the share of freight shipped by each mode remains constant over this 

time period.

FRA Also Faces Several 

Emerging Challenges to its 

Oversight of Rail Safety

Increases in Rail Freight 

Volume
 

Page 29 GAO-14-85 Rail Safety

the recent accident at Lac Mégantic, Quebec, has shown, movement of 

hazardous materials, such as petroleum products, also involves the 

potential for severe accidents. Increases in freight rail volumes and 

shipment patterns, including the possible impact of the Panama Canal’s 

widening in 2014, could result in shifts in railroad operations, which would 

increase the need for FRA safety personnel in locations where they may 

not currently be positioned.36 However, as previously discussed, FRA’s 

staffing process may not be flexible enough to respond quickly to such 

shifts. For example, FRA’s tools for allocating its inspector resources rely 

on past accident data and inspection points. Although the data and 

models are updated periodically, it can take some time for the models’ 

results (i.e., the inspection and staff allocation targets) to reflect new 

railroad infrastructure or shifting freight traffic. In addition, as previously 

discussed, FRA headquarters and regional officials stated it can take 

between 4 to 6 months and up to 4 years to get new inspectors hired, 

trained, and qualified to conduct inspections on their own.

In response to the rapid increase in rail traffic due to increased energy 

production, FRA headquarters officials have made a few temporary 

adjustments to respond to changes in traffic flows in some areas. For 

example, FRA responded to changes resulting from the development of 

the oil fields in North Dakota, where FRA did not have many inspectors, 

by reallocating an inspector position from inside the region, now assigned 

to Montana and North Dakota due to a recent vacancy. FRA regional 

officials said that it can be challenging to hire qualified inspectors for 

these affected areas or permanently relocate qualified inspectors there, 

but they do not see a need to reallocate any additional resources at this 

time.

PTC is a significant technological change for the railroads and represents 

a groundbreaking new technology, unlike other aspects of railroad 

technology and operations. As we have previously reported, PTC is a 

communications-based system designed to prevent certain types of rail 

accidents caused by human factors, such as train-to-train collisions.37

 

36However, according to a recent United States Army Corps of Engineers report, while the 

widening of the Panama Canal will double the Canal’s capacity, it is uncertain how that 

new capacity will drive intermodal freight logistics and infrastructure investment in the 

United States. Institute for Water Resources, United States Army Corps of Engineers, 

U.S. Port and Inland Waterways Modernization: Preparing for Post-Panamax Vessels 

(Washington, D.C., June 20, 2012). 

37GAO-13-720. 

Positive Train Control (PTC)
 

Page 30 GAO-14-85 Rail Safety

PTC technology can automatically slow or stop a train that is not being 

operated safely due to some types of operator errors or a switch left in the 

wrong position. Further, PTC implementation is a complex and costly 

endeavor that touches almost every part of major rail lines and almost 

every aspect of their train operations. According to FRA, railroads 

required to implement PTC must do so on over 60,000 miles of track

nationwide. In addition, FRA has reported that railroads must design, 

produce, and install more than 20 major PTC components, such as data 

radios for locomotive communication, locomotive management 

computers, and back office servers as part of the PTC implementation.38

When deployed, PTC systems will include hardware and software 

applications inside locomotives, stationary wayside detection devices and 

in centralized control facilities that will cut across the silos of FRA’s 

traditional rail safety disciplines.39 Given the recent development of PTC, 

according to both FRA and railroad officials, there is not a large pool of 

expertise either inside or outside of FRA with extensive background in the 

operation of PTC systems.

FRA officials want to hire additional staff to oversee the certification and 

testing of PTC systems and believe that they will need more specialists in 

PTC to do so.40 While FRA has determined that these specialists will be a 

new discipline that will fall outside of FRA’s traditional compliance-based 

inspection rail safety oversight framework, FRA has not yet determined 

how many PTC specialists it will need or how they will be trained to 

oversee the new technology. FRA officials stated that they are looking to 

expand the agency’s typical hiring pool to find specialists with the 

required expertise to oversee how PTC systems will be developed, 

tested, and maintained. However, FRA officials also stated that to date, 

 

38GAO-13-720. 

39RSIA mandated the implementation of positive train control (PTC) systems by 

December 31, 2015, on mainlines used to transport inter-city rail passengers, commuters, 

or any amount of certain toxic materials. Pub. L. No. 110-432, § 104. We found that most 

railroads that are required to have PTC in place reported that they will not meet this 

deadline. We reported that Congress should consider amending RSIA to grant FRA the 

authority to extend the PTC deadline on a case-by-case basis, to grant provisional 

certification of PTC systems before final system completion and to approve the use of 

alternative safety technologies in lieu of PTC. GAO-13-720. 

40Currently, FRA has 10 PTC specialists, 3 other staff, and 1 supervisor who are 

responsible for reviewing and approving PTC system certification for the 37 railroads that 

will eventually be required to have operational, integrated PTC systems. 
 

Page 31 GAO-14-85 Rail Safety

they have had little success competing with railroads and railroad 

suppliers to hire specialists.

FRA is currently facing some difficulty in recruiting, training, and certifying 

qualified inspectors in a timely manner. FRA’s need to find an inspector 

for a certain discipline in specific geographic regions and to hire new PTC 

and safety risk reduction specialists can have an effect on FRA’s ability to 

have certified inspectors where they are most needed. FRA regional 

administrators told us they were dissatisfied with the hiring process, which 

they perceive as slow and cumbersome and which can lengthen the time 

required to get a new inspector qualified to begin inspections. The speed 

of the hiring process is important since FRA officials estimate that 150 

inspectors (about 30 percent of the current field safety workforce) will be 

eligible to retire over the next 5 years. FRA also competes with the 

railroad industry to hire qualified inspector candidates for their existing 

disciplines as well as PTC and safety risk reduction specialists. FRA 

headquarters officials stated that they were confident that they could 

recruit replacements and that not all inspectors may retire immediately 

when they are eligible. FRA headquarters officials stated that they have 

also hired some PTC and comprehensive rail safety risk reduction 

specialists; however, as these areas are new to FRA and FRA’s oversight 

framework for them has not yet been fully implemented, FRA officials did 

not know how many more PTC or safety risk reduction specialists they 

will need to hire for these areas.

In addition to recruiting and certifying their inspectors and specialists, 

FRA must determine how to keep its growing and highly specialized 

workforce trained. Implementation of PTC will require extensive training of 

the FRA specialists responsible for its oversight, both initially as it is being 

developed and over time as the system is tested, implemented, and 

improved. Safety risk reduction specialists may also need ongoing 

training to keep up with new developments or standards in their field. FRA 

headquarters officials stated that they do not have a formal training plan 

that addresses the training needs for FRA’s anticipated new rail safety 

oversight responsibilities, such as PTC or safety risk reduction plans. In 

addition, FRA regional administrators also expressed concern about both 

continuing “refresher” training and training for their current inspectors 

regarding new technologies, especially for PTC. Officials from six of the 

Class I railroads we spoke with said that FRA is slow to adapt to 

advances in railroad safety technology. For example, one Class I railroad 

safety official stated that FRA’s inspectors largely inspected specific 

devices using visual observations in a straightforward, pass or fail 

inspection process. However, new technologies such as PTC are not as 

Inspector Recruitment and 

Certification

Inspector and Specialist 

Training
 

Page 32 GAO-14-85 Rail Safety

straightforward to inspect because PTC consists mainly of software, not 

physical components. Several FRA regional administrators and 

inspectors we spoke with stated that their access to training opportunities 

has been reduced in recent years due to budget constraints and that the 

lack of training opportunities has affected their ability to learn about and 

familiarize themselves with new safety technologies.

As stated above, certain railroads were mandated by RSIA to develop 

comprehensive safety risk reduction plans. According to FRA officials, 

this new approach to improving railroad safety will require FRA and the 

railroads to identify systemic safety issues as well as understand specific 

technical problems. The safety risk reduction plans will include a 

comprehensive process for the application of criteria and techniques to 

optimize safety that should help railroads to manage risk, and develop 

proactive hazard management methods that would improve safety.

According to FRA officials, once guidelines for risk reduction plans are 

developed, the railroads will draft the plans and submit them to FRA for 

approval. FRA officials stated that instead of using compliance-based 

inspections to ensure that railroads are following any FRA rules and 

regulations regarding risk reduction plans, FRA specialists will lead a 

team of FRA inspectors and specialists to audit a railroad’s compliance 

against its own plan. In addition, the officials noted that because 

comprehensive system safety is a new approach to safety, FRA’s current 

inspector workforce does not have the skill set to conduct comprehensive 

audits. Although FRA has started hiring some new specialists who are 

trained in risk reduction to complete these audits, the agency has not 

determined how many railroads will be required to develop risk reduction 

plans, how audits of the plans will be conducted, or how the results of the 

audits will be used. FRA officials noted that the agency cannot make 

many of these determinations until the final rulemaking is completed.

While FRA officials told us that they have addressed their hiring needs 

through their existing process and have been able to hire some PTC and 

safety risk reduction specialists, the agency has no formal plans to 

strategically address its human capital challenges. RSIA required FRA to 

create a long-term strategy setting out goals to improve railroad safety 

along with an annual plan that would include, among other things, 

estimates of the staff resources and training needs that are necessary to 

Comprehensive Safety Risk 

Reduction Plans

FRA’s Rail Safety Strategy 

Lacks a Strategic Human 

Capital Plan to Meet RailSafety Oversight 

Challenges
 

Page 33 GAO-14-85 Rail Safety

achieve those goals.41 Pursuant to this requirement, FRA has created a 

long-term safety strategy and included an annual plan in its annual 

budget request to Congress.42 While FRA’s safety strategy includes rail 

safety goals such as reduced accident rates from 2014 through 2018, it 

does not include estimates of staff resources or training needed to 

achieve the safety goals for those years.43 The fiscal year 2014 version of 

the strategy states that the resources needed to meet the goals in the 

strategy are contained in the fiscal year 2014 budget request. However, 

the budget request does not include an estimate of resources or training 

needed beyond fiscal year 2014, critical years in which FRA will have to 

incorporate PTC and risk reduction plans into its current rail safety 

framework. In addition, as mentioned above, all of FRA’s regional 

administrators told us that they see limitations in the process that FRA 

uses to determine staffing allocations and that FRA’s current staffing 

model may not be flexible enough to provide the appropriate inspection 

needs in their regions. FRA officials stated that they are addressing their 

human capital needs through multiple avenues including rotational 

programs, knowledge transfers between departing and new employees, 

annual training opportunities, and monitoring staffing levels for missioncritical occupations for their annual budget requests. However, these 

efforts are not coordinated and integrated into a multi-year strategic 

human capital plan.

Moreover, FRA officials stated that while they have estimated projections 

for how many inspectors they may need for the next fiscal year, due to 

uncertainty around their annual budget, and how PTC and safety risk 

reduction plans will be implemented, they do not have a formal process to 

determine staffing needs and reassess their human capital needs year by 

year. In addition, FRA officials do not know how they will integrate new 

rail safety approaches, such as implementing risk reduction plans and 

PTC, into their current rail safety oversight framework.

 

41Pub. L. No. 110-432, div. A, § 102.

42U.S. DOT, FRA, Railroad Safety Strategy: FY2014 (Washington, D.C.: January 2013) 

and Railroad Safety Strategy, FY2013-2017: Progress Assessment (Washington, D.C.: 

January 2013). 

43These rates include: highway-rail grade crossing incidents, human factor-caused train 

accidents, track-caused train accidents, equipment-caused train accidents, other (signal 

and miscellaneous) train accidents, and rail non-accidental hazardous materials releases.

In addition, FRA has a performance measure, the overall rail accidents/incidents per 

million train miles, as part of the U.S. DOT Safety Performance Goals.
 

Page 34 GAO-14-85 Rail Safety

We have reported that federal agencies need to determine the 

occupations, skills, and competencies critical to achieving their missions 

and goals, as well as to identify any gaps between their current workforce 

and the workforce they will need in the future. In addition, strategic human 

capital management is on our High Risk List.44 We have found that 

widespread lack of attention to strategic human capital management in 

the past has created a fundamental weakness in the federal 

government’s ability to perform its missions economically, efficiently, and 

effectively. To address this issue, we have determined that successful 

strategic human capital plans should:

1. involve top management, employees, and other stakeholders in 

developing, communicating, and implementing the strategic workforce 

plan;

2. determine the critical skills and competencies that will be needed to 

achieve current and future programmatic results;

3. develop strategies that are tailored to address gaps in number, 

deployment, and alignment of human capital approaches for enabling 

and sustaining the contributions of all critical skills and competencies;

4. build the capability needed to address administrative, educational, 

and other requirements important to support workforce strategies; and

5. monitor and evaluate the agency’s progress toward its human capital 

goals and the contribution that human capital results have made 

toward achieving programmatic goals.

Without a comprehensive strategic human capital plan, FRA management 

may be unable to appropriately determine the number of inspectors and 

specialists FRA needs to meet the ongoing and future challenges to its 

rail safety oversight mission and achieve its strategic rail safety goals. 

Such a plan could also help FRA management identify industry trends, 

projected retirements, skill gaps, and training needs. Without a 

comprehensive strategic plan, FRA may also not have the ability to make 

well-informed decisions about how to best meet the challenges to its rail 

safety oversight mission now and in the future. FRA also risks not having 

enough inspectors with the right skill set in the right locations across the 

country to achieve rail safety goals. In addition, FRA may not have 

 

44GAO-13-283. 
 

Page 35 GAO-14-85 Rail Safety

enough specialists to oversee the rail industry’s implementation of both 

PTC and railroad safety risk reduction plans.

FRA faces several current and evolving challenges to its rail-safety 

oversight mission. In addition to being a relatively small agency compared 

to the industry it oversees, recent legislation has expanded its 

responsibilities at the same time as federal budgets have been 

constrained. In particular, RSIA mandated that FRA implement a risk 

reduction program—an effort that incorporates a more comprehensive 

risk-based approach to safety and represents a significant procedural and 

cultural change for FRA and the railroad industry. FRA has slowly taken 

steps to implement the risk reduction program, but the agency missed the 

mandated October 2012 deadline requiring certain railroads to develop 

and implement risk reduction plans. While the agency expects to 

complete the regulations in 2015, FRA has not developed a detailed 

strategy to manage the oversight of this effort to avoid further delays in 

issuing the regulations and to ensure the timely evaluation and approval

of the railroads’ risk reduction plans when they are developed.

In addition, FRA must compete with the railroad industry for qualified 

inspectors to support the FRA’s existing rail safety oversight framework 

as well as for new safety specialists to oversee railroads’ implementation 

of their safety risk reduction plans and new PTC systems. While FRA has 

long-term rail safety goals, it does not have a corresponding human 

capital strategy that lays out: 1) the resources it needs to achieve those 

goals, 2) how it will meet its current limitations to its staffing process, 3) 

how to maintain the existing workforce in numbers or training, 4) how it 

will meet its new PTC requirements and safety risk reduction plan 

initiative, or 5) meet future changes in freight flows. The uncertainty FRA 

faces regarding its future budgets in light of these human capital 

challenges underscores the need for FRA to focus and plan how it will 

recruit, train, deploy and retain its workforce to meet these challenges.

Without a plan, FRA risks not having a skilled and trained workforce, 

deployed in the right technical domains, to meet present and future 

challenges to the FRA’s rail-safety oversight framework, especially to 

oversee the railroad industry’s implementation of positive train control and 

comprehensive rail safety risk reduction plans. Although a strategic 

human capital plan does not guarantee FRA the resources it may need to 

meet these challenges, it could help FRA better align its strategic railsafety goals and objectives with its limited resources to meet these 

human capital challenges. In addition, such a plan would demonstrate to 

Conclusions 
 

Page 36 GAO-14-85 Rail Safety

internal and external stakeholders how FRA officials could proactively 

meet these challenges and define FRA’s rationale for those decisions, 

providing greater assurance that FRA officials are prioritizing resources to 

mitigate the largest rail-safety oversight risks and better prevent rail 

accidents.

To help ensure that the Federal Railroad Administration timely and 

effectively implements oversight of railroad risk reduction programs, 

manages its limited resources, and accounts for the evolving rail safety 

environment, we recommend that the Secretary of Transportation direct 

the Administrator of the Federal Railroad Administration to:

(1) develop an implementation plan for oversight of risk reduction 

programs for passenger and freight railroads, including interim milestones 

for finalizing its rulemaking and milestones for the review and approval of 

the plans; and

(2) develop a strategic human capital plan that identifies and prioritizes 

FRA’s human capital needs and links them to FRA’s strategic goals and 

objectives. This plan should include specific approaches for how FRA will 

recruit, train, and retain both its current inspectors as well as its new 

workforce of PTC and safety risk management specialists.

We provided a draft of this report to the Department of Transportation for 

review and comment. In an email response, DOT reiterated its 

commitment to continuous rail safety improvement and stated that GAO’s 

review of FRA’s railroad safety oversight program had provided useful 

findings and recommendations for improving the program. DOT agreed to 

consider our recommendations and also provided technical comments 

that we incorporated as appropriate.

If you have any questions about this report, please contact me at (202) 

512-2834 or flemings@gao.gov. Contact points for our Offices of 

Recommendations for 

Executive Action

Agency Comments
 

Page 37 GAO-14-85 Rail Safety

Congressional Relations and Public Affairs may be found on the last page 

of this report. Major contributors to this report are listed in appendix II.

Susan Fleming

Director, Physical Infrastructure Issues
Appendix I: Objectives, Scope, and 

Methodology

Page 38 GAO-14-85 Rail Safety

This report assesses the Federal Railroad Administration’s (FRA) 

approach to railroad safety oversight as well as ongoing and emerging 

issues affecting rail safety oversight. We addressed the following 

objectives: 1) What is the overall framework that FRA, the states, and the 

railroads use to ensure safety of railroad operations and infrastructure? 2) 

To what extent do FRA and the railroads assess safety risks and allocate 

resources to address those risks? 3) What are the challenges to FRA’s 

current safety framework, and what are the ongoing and emerging issues 

FRA faces in railroad safety oversight?

To address all objectives, we reviewed documentation from FRA 

including applicable laws and regulations. We interviewed FRA 

headquarters and region officials including administrators and specialists 

for each railroad safety discipline, and state rail safety officials as well as 

representatives from all Class I and selected Class II and III railroads, rail 

labor organizations, and representatives from selected industry 

stakeholders.1 We also reviewed and analyzed reportable accident and 

incident data from 2003 through 2012 obtained from the FRA’s Railroad 

Accident and Incident Reporting System (RAIRS) database. We 

conducted a data reliability assessment of the RAIRS database by 

interviewing knowledgeable agency officials, reviewing data and 

documents, and conducting electronic testing of the data. We determined 

that the data were complete, reasonable, and sufficiently reliable for the 

purposes of this report. These data were used to obtain current and 

historical descriptive statistics on train accidents across the nation and to 

make high-level comparisons about railroad safety across regions, 

classes of railroads, and primary causes of accidents, including accidents 

related to highway-rail grade crossings and weather.

To determine the overall railroad safety framework that FRA, the states, 

and the railroads use to ensure safety of railroad operations and 

infrastructure, we examined applicable laws and regulations including the 

Rail Safety Improvement Act (RSIA) of 2008, FRA guidance, and other 

documentation, including a recent Department of Transportation Inspector 

General report and prior GAO reports describing the oversight 

 

1

The Surface Transportation Board classifies freight railroads based on annual revenues.

As of 2011 (the last year of data available), Class I freight railroads are those railroads 

that earn more than $433 million annually, Class II earn from about $35 million to $432 

million annually, and Class III railroads earn less than about $35 million annually.

Appendix I: Objectives, Scope, and 

Methodology 
Appendix I: Objectives, Scope, and 

Methodology

Page 39 GAO-14-85 Rail Safety

mechanisms that FRA uses to ensure railroad safety.2 We conducted site 

visits to three of FRA’s eight regions, including Atlanta, Georgia (Region 

3), Chicago, Illinois (Region 4), and Fort Worth, Texas (Region 5). These 

regions together accounted for over 50 percent of all train accidents that 

occurred from 2003 through 2012. We selected these regions using 

criteria that included the number and mix of Class I, II and III railroads 

operating in the region, the highest number of reportable train accidents 

during the last 10 years in each region, including highway-rail grade 

crossing accidents as determined by our analyses of FRA accident data, 

and the extent to which the region had state safety inspectors. We also 

used FRA accident and incident data to identify the four FRA regions with 

the highest number of reportable train accidents for Class II and Class III 

railroads from 2003 through 2012. Within these four regions (Regions 1, 

3, 4, 5), we selected a non-probability sample of 11 different Class II and 

Class III railroads to learn their perspectives about federal and state 

railroad-safety oversight including the extent of federal and state 

coordination and the frequency of inspections at their railroads. We 

interviewed eight FRA regional administrators and 15 FRA safety 

specialists, the FRA State Program Manager and five state railroad-safety 

program managers in California, Florida, Illinois, and Texas to understand 

their railroad safety framework and programs and the extent that FRA and 

state safety officials coordinate with each other to oversee railroad safety.

We also interviewed operations and safety representatives from all seven 

Class I railroads, three Class II railroads, eight Class III railroads, and two 

railroad holding companies that own over 100 Class III railroads to 

understand their railroad safety framework and programs, including how 

railroads conduct their own inspections and oversight to ensure railroad 

safety. The results of the interviews in the selected FRA regions, states, 

 

2

GAO, Rail Safety: The Federal Railroad Administration Is Taking Steps to Better Target 

Its Oversight, but Assessment of Results Is Needed to Determine Impact, GAO-07-149

(Washington, D.C.: Jan. 26, 2007); Rail Safety: The Federal Railroad Administration Is 

Better Targeting Its Oversight, but Needs to Assess the Impact of Its Efforts, 

GAO-07-390T (Washington, D.C.: Jan. 30, 2007); Rail Safety: The Federal Railroad 

Administration Is Better Targeting Safety Risks, but Needs to Assess Results to 

Determine the Impact of Its Efforts, GAO-07-841T (Washington, D.C.: May 22, 2007); Rail 

Safety: Preliminary Observations on Federal Rail Safety Oversight and Positive Train 

Control Implementation, GAO-13-679T (Washington, D.C.: June 19, 2013). DOT, Office of 

Inspector General Audit Report: FRA Is Nearing Completion of Rules Required by the Rail 

Safety Improvement Act, but Needs to Improve Oversight, CR-2013-070 (Apr. 17, 2013).
Appendix I: Objectives, Scope, and 

Methodology

Page 40 GAO-14-85 Rail Safety

and railroads are not generalizable to all the FRA regions, participating 

states,3 or across all Class II and III railroads.

To determine the extent to which FRA and the railroads assess safety 

risks and allocate their resources to address those risks, we reviewed 

FRA documentation on the NIP process and the SAM model and 

interviewed FRA Office of Safety Analysis officials as well as all FRA 

regional administrators and FRA regional specialists in FRA Regions 3, 4 

and 5. We used standard economic and statistical principles as criteria to 

assess the general reasonableness of the approach and assumptions 

used in FRA’s Staff Allocation Model and its National Inspection Plan 

model. We reviewed FRA’s approach for ensuring the reliability of the 

data used in the NIP process and SAM model. In addition, we interviewed 

all eight FRA regional administrators and FRA Regions 3, 4, and 5 safety 

specialists to discuss the usefulness of the NIP process and models and 

other tools that track inspector activity and allocate resources based on 

risk. We also obtained information on the status of FRA’s implementation 

of its rulemaking regarding railroads’ Risk Reduction Plans, as required 

by RSIA. We interviewed representatives from all seven Class I railroads 

about how they managed their safety risks, allocated inspection and other 

resources based on risk, and responded to changes in safety risks. We 

also interviewed officials at selected Class II and III railroads as well as 

rail labor organizations and other industry associations to understand 

their safety challenges and how they managed their risks.

To identify challenges in safety oversight and emerging safety issues that 

FRA and railroads face, we interviewed FRA headquarters officials about 

changes in safety risks and FRA’s plans to respond to those changes. We 

interviewed all FRA regional administrators and FRA Region 3, 4, and 5 

specialists for each rail safety discipline. We also interviewed state 

railroad safety program managers in California, Florida, Illinois, and 

Texas and representatives from all seven Class I railroads, selected 

Class II and III railroads, and seven rail labor organizations about 

emerging safety issues and challenges posed by adverse weather and 

 

3

As already mentioned, 30 of the 50 states and the District of Columbia (not including 

Puerto Rico and the U.S. territories) participate in the FRA’s State Rail Safety Participation 

Program. States employ safety inspectors in the five rail safety inspection disciplines. 

State programs emphasize planned, routine compliance inspections; however, states may 

undertake additional investigative and surveillance activities consistent with overall 

program needs and individual state capabilities.
Appendix I: Objectives, Scope, and 

Methodology

Page 41 GAO-14-85 Rail Safety

new railroad technologies. We also discussed with these groups ongoing 

issues related to highway-rail grade crossing safety. In addition, we 

observed railroad operating and safety practices, as well as railroad 

equipment and procedures used to ensure safety. Further, we were 

provided a tour of selected Class I and II training centers and the types of 

training provided to railroad employees, such as how simulators were 

being used to ensure safety. We also interviewed rail labor organization 

and railroad officials at selected Class II and III railroads to understand 

emerging safety risks and challenges at smaller railroads. Finally, we 

interviewed and obtained documentation from FRA headquarters officials 

on their initiatives to meet human capital requirements, such as hiring 

specialists and providing training to meet the emerging challenges and 

changes in the railroad industry.

We conducted this performance audit from December 2012 to November 

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

We met with or contacted the following organizations in order to obtain a 

better understanding of railroad safety issues and obtain their 

perspectives on FRA’s oversight approach.

Federal Highway Administration (FHWA)

Burlington Northern Santa Fe Railway Company (BNSF)

Canadian National Railway (CN)

Canadian Pacific Railway (CP)

CSX Transportation, Inc. (CSX)

Kansas City Southern Railway (KCS)

Norfolk Southern Railway Company (NS)

Union Pacific Railroad Company (UP)

National Railroad Passenger Corporation (Amtrak)

Northeast Illinois Regional Commuter Rail Corporation (Metra)

Organizations Interviewed

Other federal agencies:

Freight railroads (Class I):

Passenger railroads:
Appendix I: Objectives, Scope, and 

Methodology

Page 42 GAO-14-85 Rail Safety

Brownsville & Rio Grande Railroad

Chicago Terminal Railroad

Finger Lakes Railway

Florida East Coast Railway

Fort Worth and Western Railroad

Illinois Railway, LLC

Indiana Rail Road Company

Louisiana & Delta Railroad

Pioneer Valley Railroad

Providence and Worcester Railroad

The Bloomer Line

Genesee & Wyoming Inc.

Iowa Pacific Holdings

American Short Line and Regional Railroad Association

Association of American Railroads

Association of State Rail Safety Managers

American Train Dispatchers Association (ATDA)

Brotherhood of Locomotive Engineers and Trainmen (BLET)

Brotherhood of Maintenance of Way Employees Division of the 

International Brotherhood of Teamsters (BMWE)

Brotherhood of Railroad Signalmen (BRS)

International Association of Sheet Metal, Air, Rail and Transportation 

Workers (SMART)

International Brotherhood of Electrical Workers (IBEW)

Transportation Trades Department, AFL-CIO (TTD)

California Public Utilities Commission

Florida Department of Transportation

Illinois Commerce Commission

Texas Department of Transportation

Operation Lifesaver

Regional and short line 

(Class II and Class III) 

railroads:

Holding companies:

Industry associations:

Rail labor organizations:

State oversight 

organizations: 

Safety association:
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 43 GAO-14-85 Rail Safety

Susan Fleming, (202) 512-2834 or flemings@gao.gov

In addition to the contact named above, other key contributors to this 

report were Susan Zimmerman (Assistant Director), Melissa Bodeau, 

Richard D. Brown, Aisha Cabrer, Robert Ciszewski, Tim Guinane, Greg 

Hanna, Rick Jorgenson, Sara Ann Moessbauer, Joshua Ormond, and 

Crystal Wesco.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(541103)
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