SPECIAL NTSB INVESTIGATION REPORT ON RAILROAD AND RAIL TRANSIT ROADWAY WORKER PROTECTION

Special NTSB Investigation Report on Railroad and Rail Transit Roadway Worker Protection

NTSB Number: SIR-14-03
NTIS Number: PB2015-100583
PDF

Abstract

During 2013, 11 railroad roadway workers died while doing their jobs, representing the largest number of railroad roadway workers killed while on duty in 1 year since 1995, when 12 died. Also in 2013, four rail transit roadway workers died. This special investigation report describes the results of a National Transportation Safety Board (NTSB) investigation of these 15 deaths. The report identifies and discusses the circumstances of these deaths, which included falls from bridges, incidents involving bucket lifts, strikes by moving equipment, and natural hazards, including a mudslide. The report also identifies the following recurring safety issues: job briefings, regulation and safety oversight, the Fatality Analysis of Maintenance-of-Way Employees and Signalmen Committee, and safety culture and safety management systems. Safety recommendations to the Federal Railroad Administration, the Federal Transit Administration, the Occupational Safety and Health Administration, and the Fatality Analysis of Maintenance-of-Way Employees and Signalmen Committee are included.

Conclusions

1. Roadway workers are exposed to diverse hazards in their expected work environments.
2.  A comprehensive job briefing that could reasonably expect to prevent accidents should include specific criteria as do the Occupational Safety and Health Administration standards at Title 29 Code of Federal Regulations Parts 1910 and 1926.
3. Regulations for rail transit similar to those for railroads establishing roadway worker protection and ensuring job safety briefings that include hazard recognition and mitigation would harmonize rules and procedures and incorporate lessons learned from railroad regulation.
4. National inspection protocols for roadway work activities are necessary to ensure the safety of roadway workers on transit properties.
5. Safety would be enhanced if all rail transit agencies were required to comply with Occupational Safety and Health Administration standards.
6. As the bucket lift accidents illustrate, the differences between Federal Railroad Administration regulations and Occupational Safety and Health Administration standards may lead to confusion for those planning and executing work.
7. The Fatality Analysis of Maintenance-of-Way Employees and Signalmen Committee has not reviewed fatalities in "related incidents" because those employees did not meet the Federal Railroad Administration definition of "roadway worker."
8. To recognize dangerous tasks and activities, roadway workers need to know what to look for to identify these workplace hazards.
9. Every railroad and rail transit work site contains risks beyond those associated with on-track protection and those risks should be managed.
10. Union representation brings operations-specific knowledge to the accident investigation team and helps facilitate the cooperation of employees.

Safety Recommendations

New Recommendations

As a result of this investigation, the National Transportation Safety Board makes the following new safety recommendations:

R-14-033-043.pdf
R-14-044-046.pdf
R-14-047.pdf

To the Federal Railroad Administration:

Revise the portions of Title 49 Code of Federal Regulations (CFR) Part 214 for comprehensive job briefings for roadway workers to include the best practices in the Occupational Safety and Health Administration standards contained in Title 29 CFR Parts 1910 and 1926. (R-14-33)

Revise your national inspection program to include specific emphasis on roadway worker activities, including emphasizing hazard recognition and mitigation in job briefings. (R-14-34)

Work with the Occupational Safety and Health Administration (OSHA) to establish clear guidelines for use by railroads and railroad workers detailing when and where OSHA standards are to be applied. (R-14-35)

To the Federal Railroad Administration and the Federal Transit Administration:

Require initial and recurring training for roadway workers in hazard recognition and mitigation. Such training should include recognition and mitigation of the hazards of tasks being performed by coworkers. (R-14-36)

Include union participation in accident investigations similar to that allowed by the Occupational Safety and Health Administration. Seek authority from Congress to allow such participation, if necessary. (R-14-37)

To the Federal Transit Administration:

With assistance from the Federal Railroad Administration and the Occupational Safety and Health Administration, establish roadway worker protection rules, including requirements for job briefings. (R-14-38)


Once the action specified in Safety Recommendation R-14-38 is completed, update the state safety oversight program to ensure that rail transit systems are meeting the safety requirements for roadway workers. (R-14-39)

Establish a national inspection program that specifically includes roadway worker activities. (R-14-40)

Revise Title 49 Code of Federal Regulations (CFR) Part 659 to require all federally funded rail transit properties to comply with 29 CFR Parts 1904, 1910, and 1926. (R-14-41)

Establish an agreement with the Occupational Safety and Health Administration to collaborate on any investigation of the fatality of an on-duty rail transit employee. (R-14-42)

Establish a committee for rail transit, similar to the Fatality Analysis of Maintenance-of-Way Employees and Signalmen Committee, that includes participation from interested parties, analyzes all rail transit employee fatalities, and makes recommendations that, when implemented, will prevent future accidents. (R-14-43)

To the Federal Railroad Administration and the Occupational Safety and Health Administration:

Assist the Federal Transit Administration in establishing roadway worker protection rules, including requirements for job briefings. (R-14-44)

To the Occupational Safety and Health Administration:

Work with the Federal Railroad Administration to establish clear guidelines for use by railroads and railroad workers detailing when and where Occupational Safety and Health Administration standards are to be applied. (R-14-45)

Establish an agreement with the Federal Transit Administration to collaborate on any investigation of the fatality of an on-duty rail transit employee. (R-14-46)

To the Fatality Analysis of Maintenance-of-Way Employees and Signalmen Committee:

Include in your publications data on all roadway worker fatalities, regardless of whether the employee is performing roadway worker tasks as defined by the Federal Railroad Administration. (R-14-47)

Previously Issued Recommendation Reiterated and Reclassified in This Report

As a result of this investigation, the National Transportation Safety Board reiterates and reclassifies from "Open–Acceptable Response" to "Open–Unacceptable Response" the following safety recommendation:

To the Washington Metropolitan Area Transit Authority:

Promptly implement appropriate technology that will automatically alert wayside workers of approaching trains and will automatically alert train operators when approaching areas with workers on or near the tracks. (R-08-4)