Rail Safety: The Federal Railroad Administration Is Better Targeting Its Oversight, but Needs to Assess the Impact of Its Efforts
Published: 2007-01-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Although the overall safety record of the railroad industry, as measured by the number of train accidents per million miles traveled, has improved markedly since 1980, there has been little or no overall improvement over the past decade. Serious accidents resulting in injuries and deaths continue to occur, such as one in Graniteville, South Carolina, that resulted in 9 deaths and 292 injuries. The Federal Railroad Administration (FRA) develops safety standards and inspects and enforces railroads' compliance with these standards. On January 26, 2007, GAO reported on FRA's overall safety oversight strategy. (See GAO-07-149 .) The report discussed how FRA (1) focuses its efforts on the highest priority risks related to train accidents in planning its oversight, (2) identifies safety problems on railroad systems in carrying out its oversight, and (3) assesses the impact of its oversight efforts on safety. GAO recommended that FRA (1) put into place measures of the results of its inspection and enforcement programs and (2) evaluate its enforcement program. In reviewing a draft of that report, the Department of Transportation did not provide overall views on its contents or its recommendations. The statement is based on GAO's recent report.
section_title: What GAO Found
paragraphs: In planning its safety oversight, FRA is focusing its efforts on the highest priority risks related to train accidents through initiatives aimed at addressing their main causes--human behaviors and defective track--as well as through improvements in its inspection planning approach. FRA's May 2005 National Rail Safety Action Plan, the agency's overall strategy for targeting its oversight at the greatest risks, provides a reasonable framework for guiding these efforts. FRA's initiatives to address the most common causes of accidents are promising, although the success of many of them will depend on voluntary actions by the railroads. In addition, under the action plan, FRA has adopted a new inspection planning approach in which inspectors focus their efforts on locations that data-driven models indicate are most likely to have safety problems. In carrying out its safety oversight, FRA identifies a range of safety problems on railroad systems mainly by determining whether operating practices, track, and equipment are in compliance with minimum safety standards. However, FRA is able to inspect only about 0.2 percent of railroads' operations each year, and its inspections do not examine how railroads are managing safety risks throughout their systems that could lead to accidents. Such an approach, as a supplement to traditional compliance inspections, is used in the oversight of U.S. commuter railroads and pipelines and of Canadian railroads. GAO did not recommend that FRA adopt this approach because the agency's various initiatives to reduce the train accident rate have not yet had time to demonstrate their effects on safety. FRA uses a range of goals and measures to assess the impact of its oversight, such as (1) goals to target its inspection and enforcement programs at reducing various types of railroad accidents and (2) related measures, such as rates of track-caused accidents, to monitor its progress. However, FRA's ability to make informed decisions about these programs is limited because it lacks measures of their direct results, such as the correction of identified safety problems. Furthermore, FRA has not evaluated the effectiveness of its enforcement program.

section_title: Letter
paragraphs: We appreciate the opportunity to participate in this hearing today to  discuss the Federal Railroad Administration’s (FRA) rail safety oversight  activities. Although the overall safety record in the railroad industry, as  measured by the number of train accidents per million miles traveled, has  improved markedly since 1980, there has been little or no overall  improvement over the past decade. (See fig. 1.) Serious accidents resulting  in injuries, deaths, and property damage continue to occur.
My remarks center on work we have recently completed on FRA’s overall  safety oversight strategy. Specifically, we examined how FRA (1) focuses  its efforts on the highest priority risks related to train accidents in  planning its safety oversight, (2) identifies safety problems on railroad  systems in carrying out its oversight, and (3) assesses the impact of its  oversight efforts on safety. Our findings are discussed in more detail in our  report, which was released last week.
Our work was based on a review of laws, regulations, and FRA plans and  guidance as well as discussions with FRA officials and with a range of  external stakeholders, including railroads, unions, and state railroad safety  organizations. We reviewed FRA inspection and enforcement data for 1996  through 2005. In addition, we examined risk management principles and  safety oversight approaches used by other modal administrations within  the Department of Transportation and other organizations that have  similar safety missions in order to determine their possible application to  FRA. Our work focused on FRA oversight efforts to reduce the rate of  train accidents rather than those to reduce highway-rail crossing and  trespassing accidents because (1) the Department of Transportation’s  Inspector General has recently assessed efforts to reduce highway-rail  crossing accidents and (2) trespassing accidents primarily involve issues  not related to railroad safety performance. As part of our review, we  assessed internal controls and the reliability of the data elements needed  for this engagement and determined that the data elements were  sufficiently reliable for our purposes. We conducted our work from  November 2005 through January 2007 in accordance with generally  accepted government auditing standards.
In planning its safety oversight, FRA is focusing its efforts on the highest  priority risks related to train accidents through various initiatives aimed at  addressing the main causes of these accidents as well as through  improvements in its inspection planning approach. The agency’s overall  strategy for targeting its oversight at the greatest risks is the National Rail  Safety Action Plan, which FRA issued in May 2005. This plan provides a  reasonable framework for guiding the agency’s efforts to improve its  oversight. It includes initiatives to address the two main causes of train  accidents—human factors and defective track—and FRA has pursued  some additional initiatives to address these causes since issuing the plan.  These initiatives—which include new regulations, research on new  technologies and approaches for improving safety, and new vehicles for  inspecting track—are promising. However, most of them have not yet been  fully implemented, and their overall impact on safety will probably not be  apparent for a number of years. Furthermore, the ability of many of these  efforts to improve safety will depend on voluntary actions by railroads. In  addition, the action plan announced a new approach for planning  inspections that uses data-driven models to focus inspectors’ efforts on  locations that are likely to have safety problems.
In carrying out its safety oversight, FRA identifies safety problems on  railroad systems mainly through routine inspections that determine  whether operating practices, track, and equipment, such as signals and  locomotives, are in compliance with minimum safety standards. However,  FRA inspections cover only about 0.2 percent of railroads’ operations each  year. Also, these inspections are not designed to determine how well  railroads are managing safety risks throughout their systems that could  lead to accidents. The American Public Transportation Association  (APTA), the Pipeline and Hazardous Materials Safety Administration  (PHMSA), and Transport Canada have implemented approaches to  oversee the management of safety risks by U.S. commuter railroads, U.S.  pipelines, and Canadian railroads, respectively. These oversight  approaches complement, rather than replace, traditional compliance  inspections and, therefore, provide additional assurance of safety.
FRA uses a broad range of goals and measures to assess the impact of its  oversight efforts on safety. For example, it has developed new goals to  target its inspection and enforcement efforts at reducing various types of  railroad accidents and related measures to track its progress. However,  FRA lacks measures of the direct results of its inspection and enforcement  programs, such as measures of the extent to which these programs have  resulted in the correction of identified safety problems. Furthermore, FRA  has not evaluated the effectiveness of its enforcement program in  achieving desired results. Both performance measures and evaluations can  provide valuable information on program results that helps hold agencies  accountable for the performance of their programs. In our recent report,  we recommended that FRA develop and implement measures of the direct  results of its inspection and enforcement programs and evaluate its  enforcement program. FRA reviewed a draft of our report but did not  comment on our recommendations.
subsections: section_title: Background
paragraphs: On average, about 450 people have been injured and 14 people have been  killed in train accidents each year over the past decade, from 1996 through  2005, exclusive of highway-railroad grade crossing and trespassing  accidents. In recent years, a number of serious accidents raised concerns  about the level of safety in the railroad industry. For example, as you are  aware, in 2005, a train collision in Graniteville, South Carolina, resulted in  the evacuation of 5,400 people, 292 injuries, and 9 deaths.
FRA develops and enforces regulations for the railroad industry that  include numerous requirements related to safety, including requirements  governing track, signal and train control systems, grade crossing warning  device systems, mechanical equipment—such as locomotives and tank  cars—and railroad operating practices. FRA also enforces hazardous  materials regulations issued by PHMSA as they relate to the safe  transportation of such materials by rail. FRA’s inspectors generally  specialize in one of five areas, called inspection disciplines: (1) operating  practices, (2) track, (3) hazardous materials, (4) signal and train control,  and (5) motive power and equipment. FRA’s policy is for inspectors to  encourage railroads to comply voluntarily. When railroads do not comply  voluntarily or identified problems are serious, FRA may cite violations and  take enforcement actions, most frequently civil penalties, to promote  compliance with its regulations. FRA is authorized to negotiate civil  penalties with railroads and exercises this authority. FRA conducts  additional oversight of Class I railroads through the Railroad System  Oversight program. Under this program, the agency assigns an FRA  manager for each Class I railroad to cooperate with it on identifying and  resolving safety issues.
FRA is a small agency, especially in relation to the industry it regulates. As  of July 2006, FRA had about 660 safety staff, including about 400  inspectors in the field (in its regional, district, and local offices). In  addition, 30 state oversight agencies, with about 160 inspectors,  participate in a partnership program with FRA to conduct safety oversight  activities at railroads’ operating sites. In contrast, the railroad industry  consists of about 700 railroads with about 235,000 employees, 219,000  miles of track in operation, 158,000 signals and switches, and over 1.6  million locomotives and cars.
section_title: FRA Has Made Progress in Targeting Its Oversight Efforts on the Basis of Risk
paragraphs: In planning its safety oversight, FRA focuses its efforts on the highest  priority risks related to train accidents through a number of initiatives.  FRA’s May 2005 National Rail Safety Action Plan provides a reasonable  framework for the agency’s efforts to target its oversight at the highest  priority risks. The plan outlines initiatives aimed at reducing the main  types of train accidents, those caused by human factors and track defects.  Since issuing the plan, the agency has pursued additional initiatives to  target risks posed by these causes. However, these efforts are in varying  stages of development or implementation and, while some individual  initiatives may start showing results in the next year or two, their overall  impact on safety will probably not be apparent for a number of years. FRA  has also developed a new approach for planning its inspections, based on  greater use of its accident and inspection data. While these initiatives are  promising, it is too early to assess their impact.
subsections: section_title: FRA Is Making a Number of Efforts to Reduce Accidents Caused by Human Factors and Track Defects, but Results Are Not Yet Clear
paragraphs: In 2005, 72 percent of all train accidents in the United States were  attributable to either human factors or track defects. Human factor  accidents result from unsafe acts of individuals, such as employee errors,  and can occur for a number of reasons, such as employee fatigue or  inadequate supervision or training. Recent FRA initiatives to reduce  accidents caused by human factors include    proposed regulations aimed at reducing the most common causes of these  accidents, such as improper positioning of track switches;   a 5-year pilot project to establish a confidential voluntary system for  reporting and learning from close call incidents;    a study to develop a fatigue model that could be used by railroads to  improve train crew scheduling practices and prevent worker fatigue; and   a proposed 5-year pilot project that would use risk management to help  reduce human factor accidents, as well as other types of accidents, at  selected railroad worksites.
Track defects, which can cause derailments, include rails that are uneven  or too wide apart or rails or joint bars that are cracked or broken. Key  recent FRA initiatives to reduce accidents caused by track defects include  two additional track inspection vehicles that can precisely measure track  during inspections; and   new regulations on inspections of rail joints in continuous welded rail  track and plans to develop additional regulations to improve railroads’  management of this type of track.
These initiatives are in varying stages of development or implementation  and use a variety of approaches, some quite innovative, for addressing the  causes of human factor and track accidents. While they have the potential  to eventually reduce these types of accidents, it is too early to predict their  outcomes. The human factor initiatives, except for the proposed  regulations, depend on voluntary actions by railroads, and, in some cases,  labor as well, for their success.
section_title: FRA Has Made Progress in Targeting Its Inspections on the Basis of Risk
paragraphs: FRA has developed a new approach—the National Inspection Plan—for  using available data to target its inspections at the greatest safety risks.  The plan provides guidance to each regional office on how its inspectors  within each of the five inspection disciplines should divide up their work  by railroad and state. It is based on trend analyses of accident, inspection,  and other data that predict locations where train accidents and incidents  are likely to occur within each region and provide the optimal allocation of  inspection resources to prevent accidents.
Previously, FRA had a less structured, less consistent, and less data-driven  approach for planning inspections. According to agency officials, each  region prepared its own inspection plan, based on judgments about  appropriate priorities and analysis of available data. However, the use of  data was not consistent from region to region. Inspectors had greater  discretion about where to inspect and based decisions about priorities on  their knowledge of their inspection territories.
FRA’s new approach for planning its inspection activity allows it to better  target the greatest safety risks and make more effective use of its  inspectors. However, it is not yet clear whether the new approach will lead  to a prioritization of inspection levels across regions and inspection  disciplines or improved safety.
section_title: FRA Relies Primarily on Direct Inspections to Identify Safety Problems and Does Not Oversee Railroads’ Management of Safety Risks
paragraphs: In carrying out its safety oversight, FRA identifies a range of safety  problems on railroad systems mainly through routine inspections to  determine whether operations, track, and equipment are in compliance  with safety standards. FRA’s inspections do not attempt to determine how  well railroads are managing safety risks throughout their systems. APTA,  PHMSA, and Transport Canada have implemented approaches to oversee  the management of safety risks by U.S. commuter railroads, U.S. pipelines,  and Canadian railroads, respectively. These oversight approaches  complement, rather than replace, traditional compliance inspections and  therefore provide additional assurance of safety.
subsections: section_title: FRA’s Oversight Identifies a Range of Problems on Railroad Systems
paragraphs: FRA primarily monitors railroads’ compliance through routine inspections  by individual inspectors at specific sites on railroads’ systems. Inspectors  typically cover a range of standards within their discipline during these  inspections. This inspection approach focuses on direct observations of  specific components of the train, related equipment, and railroad  property—including the track and signal systems—as well as operating  practices to determine whether they meet FRA’s standards. (See fig. 2.)  Inspectors also examine railroads’ inspection and maintenance records.  The railroads have their own inspectors who are responsible for ensuring  that railroad equipment, track, and operations meet federal rail safety  standards.
FRA also conducts more in-depth inspection efforts that generally focus  on railroads’ compliance in a particular area, such as their inspections of  employees’ adherence to operating rules. These efforts often involve a  team conducting separate inspections at multiple sites, generally within  one of FRA’s eight regions. FRA also periodically conducts in-depth  inspections of some systemwide programs that railroads are required to  implement, such as employee drug and alcohol testing programs.
In 2005, federal and state inspectors conducted about 63,000 inspections.  According to FRA, routine inspections constituted about 75 percent of the  inspections of railroads, and in-depth inspections accounted for about 11  percent. The remainder of these inspections (14 percent) consisted of  other types of activities, such as investigations of accidents and  complaints. This approach to oversight enables FRA inspectors and  managers to identify a wide range of safety problems. Inspectors identify  specific compliance problems—conditions that do not meet FRA’s  standards—at sites they visit by citing defects. Inspectors cite violations of  safety standards for those defects that they believe warrant enforcement  action. They consider a number of factors in making this decision,  including the railroad’s history of compliance at that location and the  seriousness of the noncompliance (such as whether it is likely to cause  accidents, injuries, or releases of hazardous materials). Inspectors in some  disciplines cite more defects and violations than others. (See fig. 3.)
The motive power and equipment discipline cites almost half of all defects  and over a third of all violations. FRA officials told us that the standards in  this inspection discipline are the most prescriptive, making defects and  violations easier to find. However, these types of defects cause a much  smaller proportion of accidents than human factors and track defects.  The most frequently cited violations include those for noncompliance with  standards for locomotives and freight cars, track conditions,  recordkeeping on the inspection and repair of equipment and track, and  the condition of hazardous materials tank cars.
section_title: Several Other Organizations Have Implemented Comprehensive Approaches for Overseeing the Management of Safety Risks in Transportation Industries
paragraphs: FRA officials have noted that their approach of directly inspecting safety  conditions and targeting locations that are most likely to have compliance  problems provides a safety net and holds railroad management  accountable. However, because the number of FRA and state inspectors is  small relative to the size of railroad operations, FRA inspections can cover  only a very small proportion of railroad operations (0.2 percent). Also,  FRA targets inspections at locations on railroads’ systems where accidents  have occurred, among other factors, rather than overseeing whether  railroads systematically identify and address safety risks that could lead to  accidents.
Risk management can help to improve systemwide safety by  systematically identifying and assessing risks associated with various  safety hazards and prioritizing them so that resources may be allocated to  address the highest risks first. It also can help in ensuring that the most  appropriate alternatives to prevent or mitigate the effects of hazards are  designed and implemented. A framework for risk management based on  industry best practices and other criteria that we have developed divides  risk management into five major phases: (1) setting strategic goals and  objectives, and determining constraints; (2) assessing risks; (3) evaluating  alternatives for addressing these risks; (4) selecting the appropriate  alternatives; and (5) implementing the alternatives and monitoring the  progress made and results achieved.
Other transportation oversight organizations have developed and  implemented approaches for overseeing industries’ overall management of  safety risks. In particular, during the last 10 years, APTA, PHMSA, and  Transport Canada have developed and implemented such oversight  approaches for U.S. commuter railroads, U.S. pipelines, and Canadian  railroads, respectively. These approaches complement, rather than  replace, traditional compliance inspections. APTA provides guidelines to  commuter railroads on managing the safety of their systems—including  safety risks—and audits their plans for and implementation of this  management approach. PHMSA requires that pipeline operators develop  “integrity management” programs to manage risk in areas—such as those  that are densely populated—where leaks or ruptures could have the  greatest impact on public safety and inspects operators’ compliance with  these requirements. In Canada, the department responsible for  overseeing railroad safety, Transport Canada, requires that railroads  establish safety management systems that include risk management and  assesses these systems. APTA, PHMSA, and Transport Canada have  emphasized that risk management provides a higher standard of  performance than traditional safety regulation based on compliance alone.
We have reviewed PHMSA’s gas transmission pipeline integrity  management oversight approach and have recently concluded that it  enhances public safety. Operators told us that the primary benefit of the  program is the comprehensive knowledge they acquire about the condition  of their pipelines. APTA and Transport Canada officials have told us that  their oversight approaches have not been formally evaluated to determine  their effectiveness.
FRA has taken some steps in a limited number of areas to oversee and  encourage risk management in the railroad industry. For example, the  agency has several regulations in place that require railroads to use a risk- based approach for managing safety in some specific areas, such as the  operation of high-speed passenger trains. In addition, FRA is considering  establishing a pilot project to examine how a risk management approach  could be used voluntarily in the railroad industry to reduce human factor  and other types of accidents.
Oversight of railroads’ overall approach for managing safety risks on their  systems, in addition to FRA’s existing discipline-specific, compliance- based oversight, has the potential to provide additional assurance of  safety. However, developing and implementing such a new oversight  approach would be a major undertaking for the agency, and FRA’s current  initiatives to reduce train accidents need time to mature to demonstrate  their effects. As a result, we did not recommend in our recent report that  FRA adopt an approach for overseeing railroads’ management of safety  risks.
section_title: FRA Measures Its Progress in Achieving a Variety of Safety Goals, but Has Limited Information on the Direct Results of Its Oversight
paragraphs: FRA has a broad range of goals and measures that it uses to provide  direction to and track the performance of its safety oversight activities.  However, its ability to make informed decisions about its inspection and  enforcement programs is limited because it lacks measures of the  intermediate outcomes, or direct results, of these programs that would  show how they are contributing toward the end outcomes, or ultimate  safety improvements, that the agency seeks to achieve. Furthermore, FRA  has not evaluated the effectiveness of its enforcement approach. Both  performance measures and evaluations can provide valuable information  on program results that helps hold agencies accountable for their  programs’ performance.
subsections: section_title: FRA Has Established a Range of Safety Goals and Measures, but Information on Direct Results Is Limited
paragraphs: To its credit, FRA has adopted a range of useful safety performance goals  and related measures. These goals help the agency target its oversight  efforts to achieve the department’s goals of reducing (1) the rate of rail- related accidents and incidents and (2) the number of serious hazardous  materials releases. For example, FRA has recently established new  agencywide safety goals that are aligned with its five inspection disciplines  and its grade-crossing efforts. These include goals to reduce the rates of  various types of train accidents—including those caused by human  factors, track defects, and equipment failure—as well as hazardous  materials releases and grade-crossing incidents. These departmental and  agency goals represent the key end outcomes, or ultimate results, FRA  seeks to achieve through its oversight efforts. FRA has also established  related measures that help the agency determine and demonstrate its  progress in meeting the desired goals. In addition, it has also established  similar goals and measures for each of its eight regional offices. FRA also  uses various other measures to manage its oversight efforts, such as  numbers of inspections performed and enforcement actions taken.
While FRA has developed a range of goals and measures related to its  oversight of railroad safety, it lacks measures of the desired intermediate  outcomes, or direct results, of its inspection and enforcement efforts—the  correction of identified safety problems and improvements in compliance.  (See fig. 4.) According to FRA officials, inspectors review reports on  corrective actions provided by railroads and always follow up on serious  identified problems to ensure that they are corrected. However, the agency  does not measure the extent to which the identified safety problems have  been corrected. FRA also lacks overall measures of railroads’ compliance.  Officials have emphasized that the agency relies on inspectors’ day-to-day  oversight of and interaction with railroads to track compliance.
Without measures of intermediate outcomes, the extent to which FRA’s  inspection and enforcement programs are achieving direct results and  contributing to desired end outcomes is not clear. We recognize that  developing such measures would be difficult and that it is challenging for  regulatory agencies to develop such measures. Nevertheless, some other  regulatory agencies in the Department of Transportation have done so. For  example, the Federal Motor Carrier Safety Administration measures the  percentage of truck companies that improve their performance in a follow- up inspection.
section_title: FRA Has Made Changes in Response to Evaluations but Has Not Evaluated Its Enforcement Approach
paragraphs: By examining a broader range of information than is feasible to monitor  on an ongoing basis through performance measures, evaluation studies  can explore the benefits of a program as well as ways to improve program  performance. They can also be used to develop or improve agencies’  measures of program performance and help ensure agencies’  accountability for program results. Although FRA has modified several  aspects of its safety oversight in response to external and internal  evaluations, it has not evaluated the extent to which its enforcement is  achieving desired results.
Under FRA’s current “focused enforcement” policy, developed in the mid- 1990s, inspectors cite a small percentage of identified defects (about 3  percent in 2005) as violations that they recommend for enforcement  action, generally civil penalties. While this policy relies to a great extent on  cooperation with railroads to achieve compliance and is intended to focus  FRA’s enforcement efforts on those instances of noncompliance that pose  the greatest safety hazards, it is not clear whether the number of civil  penalties issued, or their amounts, are having the desired effect of  improving compliance. Without an evaluation of its enforcement program,  FRA is missing an opportunity to obtain valuable information on the  performance of this program and on any need for adjustments to improve  this performance.
In the report we issued last week, we recommended that FRA (1) develop  and implement measures of the direct results of its inspection and  enforcement programs and (2) evaluate the agency’s enforcement program  to provide further information on its results, the need for additional data  to measure and assess these results, and the need for any changes in this  program to improve performance. FRA did not express a view on these  recommendations when it commented on our draft report. As part of our  normal recommendation follow-up activity, we will work toward FRA’s  adoption of our recommendations.
Madam Chairwoman, this concludes my prepared statement. I would be  pleased to respond to any questions that you or other Members of the  Subcommittee might have.
section_title: GAO Contacts and Staff Acknowledgement
paragraphs: For further information on this statement, please contact Katherine  Siggerud at (202) 512-2834 or siggerudk@gao.gov. Individuals making key  contributions to this testimony were Judy Guilliams-Tapia, Bonnie  Pignatiello Leer, and James Ratzenberger.
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