SUBJECT: Trainee Switching Fatality Involving a Shove Movement in a Yard

The Federal Railroad Administration (FRA) is investigating a fatality that occurred on June 26, 2023. Based on FRA’s preliminary investigation, a conductor and a conductor trainee (CT) were riding the point on an empty intermodal well car during a shoving move of a train consisting of two locomotives and 43 intermodal well cars. The CT was using a portable radio with a speaker microphone attached to his vest to communicate to the locomotive engineer. Preliminary findings suggest that, although the CT may have maintained three-point contact, his posture and position on the car were not stable enough to withstand the forces when the train slowed down and slack ran out. The CT lost his balance and fell forward into the gauge of the rail. The CT was subsequently struck by the rolling equipment, resulting in a fatality. The purpose of this Safety Bulletin, which is informal in nature, is to ensure the railroad industry is aware of this recent accident that resulted in a fatality of an employee. Its purpose is to also encourage railroads to identify location-specific safety issues to cover during safety briefings and (re)train employees. As FRA completes its investigation, it may take additional actions with respect to this accident. FRA requests that railroads review this Safety Bulletin with employees to increase awareness of the dangers of riding moving equipment and ensure employees who ride moving equipment do so safely, to include:

1. Railroads should review their training programs to ensure the programs are adequate to prepare employees to safely and properly ride moving equipment, including the handling of unexpected or unusual forces experienced while riding equipment. Training programs should ensure that both employees that oversee trainees and trainees are familiar with their duties, have received proper instruction, and are continuously monitored for compliance and safety.

2. Employees should only ride equipment when necessary for job duties, and only after the process for doing so is discussed in a job briefing. Further, employees should only ride equipment after determining it is safe to do so.

3. Employees should always face the equipment and maintain at least three-point contact to brace for changes in speed and slack action, ensuring the positioning of their feet and hands achieves optimal stability when riding rolling equipment.

4. Railroads should review with their employees Switching Operations Fatality Analysis (SOFA) Recommendation No. 5 – Mentor less experienced employees to perform services safely. The SOFA Working Group is a voluntary, non-regulatory, workplace safety partnership formed to identify commonalities among fatalities that occur during Prepared by: The Federal Railroad Administration, Office of Railroad Safety switching operations.

Issued: July 6, 2023