SUBJECT: Highway-Rail Grade Crossing and Shove Movement Accident

The Federal Railroad Administration (FRA) is investigating a recent switching accident that resulted in a crew member fatality.

Based on FRA’s preliminary investigation, a conductor with 18 years of service was fatally injured when the tank car he was riding to provide point protection for a switching move was struck by a dump truck. The incident occurred at a private grade crossing in a steel plant as the train consist traveled southward.

The dump truck, traveling west, stopped at the private highway-rail grade crossing, then proceeded and collided with the car the conductor was riding, killing the conductor. It was nighttime, the yard was lighted, and the conductor had his lantern turned on.

Prior to the incident, the conductor was in communication with the engineer via radio. The private highway-rail grade crossing was equipped with passive warning devices and stop signs.

The purpose of this Safety Bulletin, which is informal in nature, is to ensure the railroad industry, including railroad employees, are aware of this recent accident that resulted in a fatality of an employee. As FRA completes its investigation, it may take additional actions with respect to this accident.

Although FRA’s investigation into this accident is ongoing, FRA notes the importance of ensuring pushing or shoving movements over highway-rail crossings are conducted safely, to include:

  • Proper training, periodic oversight, and application of appropriate railroad operating rules when determining whether the track is clear, and
  • Proper job briefings and communications between assigned crewmembers during pushing or shoving movements.

FRA requests that railroads review this Safety Bulletin with employees to increase awareness of the dangers of pushing and shoving movements at highway-rail grade crossings. FRA also
reminds railroads of the need to ensure all individuals involved in pushing or shoving movements are: (1) properly trained and qualified on how to conduct those operations safely;
and (2) understand what “track is clear” means related to a highway-rail grade crossing.

Additionally, FRA reminds railroads and train crew members of the work of the Switching Operations Fatality Analysis (SOFA) Working Group, a voluntary, non-regulatory, workplace safety partnership formed to identify commonalities among fatalities that occur during switching operations. SOFA findings are available on FRA’s website.

View this bulletin in PDF form.

The Switching Operations Fatality Analysis (SOFA) Working Group issued a one-page information sheet last week regarding shove movements, reminding workers to take care during shove moves — “When in doubt, dismount!”

According to the flyer, 27 of 34 fatalities analyzed by the SOFA group in the decade from 2011-2021 occurred during shove moves.

The SOFA Working Group is a cross-industry collaboration for over 25 years that works to identify any possible contributing factors for each of the more than 210 switching operations fatalities that have occurred in the rail industry since 1992. The SOFA Working Group reports its findings and on emerging data trends with the goal of zero fatalities in the railroad industry.

The Switching Operations Fatality Analysis (SOFA) Working Group in June issued its latest updates on switching fatalities and severe injuries for the entirety of 2017 and for the first quarter of 2018.
According to SOFA, there were three switching-related fatalities and nine amputations as a result of switching accidents in 2017. There were 68 “severe injuries,” which SOFA defines as potentially life-threatening; having a high likelihood of permanent loss of function, permanent occupational limitation or other permanent disability; likely to result in significant work restrictions and resulting from a high-energy impact to the human body.
The number of severe injuries and amputations in 2017 exceeded 2016’s totals of 47 and seven, respectively.
SOFA reported that train accident reports increased to 1,686 in 2017 over the 1,671 in 2016. However, SOFA said that human factor accidents decreased to 639 in 2017 from the 643 reported in 2016.
In the first quarter of 2018, SOFA said there were two amputations, 20 severe injuries and no switching fatalities. SOFA reported that there have been 416 train accidents and 154 human factor accidents thus far in 2018.
SOFA is a voluntary, nonregulatory railroad safety partnership consisting of representatives of SMART Transportation Division, the Brotherhood of Locomotive Engineers and Trainmen (BLET), Federal Railroad Administration (FRA), Association of American Railroads (AAR) and the American Short Line and Regional Railroad Association (ASLRRA) that has a goal of zero switching fatalities achieved through education and nonpunitive interactions.
Click here to go to our SOFA page and read SOFA’s full reports.

Safety 1st; Safety FirstJob briefings can prevent serious injuries and fatalities, says the Federal Railroad Administration in a switching fatalities and severe injury update. The FRA cites 23 fatalities that have occurred as a result of what it terms “inadequate job briefings.”

The FRA offers the following tips for “an effective job briefing”:

* First, a job briefing is different from a safety briefing. A job briefing is specific to upcoming work and its interrelated and independent tasks. A safety briefing is more general, often occurring at the beginning of a shift

* Ongoing communication is crucial among employees during the entire time switching operations are being performed, including periods when tasks are changing or when anomalies occur. Thus, it is important always to monitor work-in-progress, especially for anomalies. When work changes occur, the employees involved may not maintain current with these changes. They may be unaware of the tasks to be performed, and this may place them in peril.

* All crew members should be empowered to stop work and request a job briefing

* A job briefing is a two-way exchange of information to reach an understanding of the tasks being performed. All should participate in the job briefing, regardless of seniority. All should be heard about concerns of upcoming work. All should understand the exact nature of work to be performed

* A job briefing cannot be standardized, generalized or simply rule based. Switching acts can be unique to circumstances and location. A briefing must be adequate and specific to the acts. Fatalities have resulted even after a job briefing because the briefing was not adequate

* At a minimum, a job briefing should include:
       * Who will act
       * What act is to be done
       * Where the act will occur
       * When the act will occur
       * Why the act is being done

* An effective job briefing can prevent harm to employees monitoring switching operations for anomalies from what was planned. Stopping work when appropriate, and holding an effective job briefing, are part of safe operating practices.

For more information on FRA safety advisories, click on the following link:

To review the first quarter, 2012, Switching Operations Fatality Analysis (SOFA) report, click on the following link: