Federal agencies Rail

Staying on track

Rail operations called on to examine behaviors that contribute to incidents


Key points

  • Distraction, complacency, poor communication and fatigue have been linked to collisions, derailments and other incidents on or near rails.
  • The National Transportation Safety Board is recommending that the Federal Transit Administration require all transit agencies to review authorization procedures for allowing workers access to tracks.
  • Experts say rail operations can improve their knowledge of why near-miss incidents occur by empowering workers to discuss them openly with their supervisors.

On Dec. 1, 2013, a Metro-North commuter train derailed in the Bronx in New York City, killing four people and injuring 59 others. The operator was running the train at nearly triple the speed limit in the zone in which it derailed. It was the city’s deadliest mass transit train derailment in more than two decades.

The National Transportation Safety Board’s early report on the Metro-North derailment indicates the operator was likely fatigued at the time of the incident.

This incident and others are drawing attention to human behavior elements that may need to be addressed in the rail industry.

After a deadly September 2008 collision between a Metrolink commuter train and a Union Pacific Railroad freight train in California, NTSB began tracking a pattern of severe train incidents that were attributed to human behavioral factors such as inattentiveness, distraction or poor judgment. In this case, the Metrolink engineer had sent and received text messages while operating the train, causing him to miss a crucial stop signal.

NTSB has included operational safety in the rail mass transit industry on its “Most Wanted” list of safety improvements for 2014, citing as major issues human behavioral factors and deficient safety cultures that do not encourage open communication between workers and supervisors. It is the first time rail mass transit operational safety has been included on NTSB’s Most Wanted list.


Complacency can be an issue among workers who have been in the rail industry for a long time, said Greg Hull, assistant vice president of public safety, operations and technical services for the American Public Transportation Association.

Employees who go decades without an incident may falsely believe nothing bad can happen, Hull said, and take a shortcut that could prove disastrous. This is particularly dangerous when a technology or procedure has changed but an older worker decides to follow a previous preferred method, Hull added.

Experienced workers are not the only ones who can become complacent. Newly hired employees may not follow all posted procedures if they were never required to do them in previous jobs, according to Pat Colliere, a safety officer in engineering for the New York Division of Amtrak. Colliere noted that the industry is becoming “younger by the minute,” as rail workers who were hired in the late 1970s during the industry’s hiring frenzy retire, taking the knowledge of a more dangerous time in the industry with them.

Fatigue and scheduling

Most freight rail engineers, conductors and signal employees are required to go off duty after 12 consecutive work hours and have 10 consecutive hours off before being called to their next assignment. Although hours-?of-service regulations established by the Rail Safety Improvement Act of 2008 are intended to ensure rail workers have enough time for rest, the 2013 Metro-North incident brought attention to the role of scheduling changes and their effect on fatigue.

At press time, the preliminary investigation of the Metro-North incident indicated that the train operator allegedly had recently switched to the early shift from the afternoon shift. The National Sleep Foundation states that changing schedules may cause fatigue as the worker adjusts to being awake during times when he or she normally would have been resting.

According to the Association of American Railroads, some train crews are unable to work set schedules for a number of reasons, including weather, track maintenance and rail traffic. AAR recommends the following solutions to help combat fatigue among rail crews:

  • Provide workers with an extra rest period if they feel excessively fatigued by the time they go off duty.
  • Make rest periods and scheduling changes more predictable.
  • Encourage workers to get screened for sleep disorders such as obstructive sleep apnea and educate them on the symptoms of daytime fatigue.
  • Make sure crews are able to receive restful sleep during their time off by improving their lodging or ensuring they make it home for off-duty periods.

Communication and situational awareness

In October 2013, two track workers were struck and killed by a Bay Area Rapid Transit train near Walnut Creek, CA, after they had gained approval from a control center to enter the track. The workers had used a notification procedure known as “simple approval” to access the track, with no protection from oncoming trains or moving equipment other than their own situational awareness.

The California Public Utilities Commission later issued new rules for rail-transit roadway workers in the state. The rules require a watchperson to be present for all rail-transit work, as well as more frequent communication among train operators, dispatchers and roadway crews.

NTSB is now recommending that the Federal Transit Administration require all transit agencies to review their authorization procedures for allowing workers access to a track, discarding any procedure similar to BART’s discontinued “simple approval” process. FTA also should require transit agencies to install additional warning or stopping devices on trains or tracks, including secondary warning systems that can notify workers on a track of oncoming trains or moving equipment, according to NTSB.

However, workers and dispatchers need to know these technologies are not an “end-all thing,” Colliere said.

“While technology does have its place in safety, there is a lot of technology out there that could give a false sense of security if used incorrectly,” he said. “For example, there are armbands that warn track workers on the approach of a train. These only work if the battery is charged and if the transponders are working.”

Improvements in rail worker safety

According to the Association of American Railroads’ most recent data, in 2012 the rate of serious or fatal injuries among rail employees was down 85 percent from 1980 and 51 percent from 2000.

Pat Colliere, a safety officer in engineering for the New York Division of Amtrak, said changes in regulations, equipment and industry best practices are some of the reasons for the improvement:

  • Personal protective equipment requirements for workers who maintain and provide switching for rails have improved, as well as the brightness and reflectivity of warning devices, Colliere said.
  • The Federal Railroad Administration’s Roadway Worker Protection standards mandate minimum requirements in flagging, signaling, right-of-way work and use of equipment on tracks adjacent to workers.
  • An FRA rule issued in 2011 requires rail operations to adopt new on-track safety procedures, including improved train approach warnings and speed limits near work areas.

Employee role in safety

NTSB also has called out rail mass transit operations for not doing enough to incorporate worker input and information on near-miss incidents into their safety programs. These workers have special insight into unsafe work processes or hazards that could result in a severe incident at a future date, noted Jeff P. Kovacs, deputy general manager of the Rail Safety and Training Department for New Jersey Transit. Kovacs said workers also are a key source of information on workplace incidents that were never reported because they did not result in property damage or an injury, among other reasons.

However, workers are not likely to begin sharing their insight or information on near-miss incidents unless an open and non-punitive safety culture exists, Kovacs said. To build a stronger dialogue between workers and supervisors, he recommends the following:

  • Supervisors should encourage workers to report all hazards and incidents they witness, even those that normally would not be reported based on the Federal Railroad Administration’s reporting requirements.
  • Use training sessions on working safely on or near the rails to gather insight into what aspects of training workers do not comprehend, and then focus on those aspects in safety briefings and other training materials.
  • Rail operations should establish anonymous reporting systems to gather information on near-miss incidents in case workers are concerned about being penalized.

Hull noted that safety regulations among rail operations have better prioritized workers’ safety, including ones that allow rail workers to refuse to perform a work function they have a reason to believe would be unsafe or put them in danger. This places part of the responsibility on the workers, he said. According to Hull, rail workers under an effective workplace safety culture will do the following:

  • Feel comfortable asking questions about procedures or any aspects of work they are required to do
  • Ensure they are properly rested before work
  • Be familiar with the rules and regulations
  • Understand what is required with the safety measures needed to be in place
  • Monitor co-workers to ensure they are working safely

“The railroad can be a dangerous place to work, and it only takes a split second to cost a life,” Colliere said.

Tip of the rail ‘safety iceberg’

Jeff P. Kovacs, deputy general manager of the Rail Safety and Training Department for New Jersey Transit, describes the fatal incidents in New York in 2013 and Chatsworth, CA, in 2008 as the tip of a “safety iceberg.” For every major incident or fatality, he said, it is likely that hundreds of less serious incidents came before it. And many were probably never reported because they were below the Federal Railroad Administration’s reporting threshold level.

In its list of “Most Wanted” safety improvements for 2014, the National Transportation Safety Board recommended rail mass transit agencies look to these near misses as a wealth of information on the roles of human error in incidents.

“The improved knowledge should be put to work by refining and strengthening operational policies, practices and procedures to manage and mitigate the safety risks,” NTSB stated.

One such way is through the Confidential Close Call Report System, which New Jersey Transit and three other major rail operations implemented as part of an FRA pilot program in the late 2000s.

At the CCCRS pilot sites, workers could submit near-miss reports through a neutral third party that removed all identifying information from the reports. They then went on to a committee comprising labor, management and FRA that identified root causes for the incidents detailed in the reports. The committee then proposed corrective actions that could be communicated back to the railroads.

As a result, New Jersey Transit incorporated results of CCCRS into the safety briefings for workers. It also redesigned safety checklists and began meeting more frequently with employees about things that could be improved at work. CCCRS allowed the operation to tailor information to what crewmembers needed to know, increasing the effectiveness of the safety program, Kovacs said.

The program not only enhanced communications among co-workers and between supervisors and front-line workers, it enhanced everyone’s safety awareness, he said. CCCRS informed safety professionals at New Jersey Transit about safety deficiencies and safety hazards they would not have known about otherwise.

“It’s difficult to quantify how much safety improvement was related to CCCRS,” he said. “It’s mostly, from our standpoint, about having healthier safety awareness.”


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