From The Ergoweb® Learning Center

Federal Agency Issues Final Rule Taking Aim at Human Factors Related Accidents

In February the Department of Transport (DOT) issued what it calls its final rule to make America’s railroads safer. Due to take effect on April 14, the rule is directed at cutting the growing number of human factors accidents. It addresses all the aspects of willful lapses. An issue that awaits expert analysis of the lengthy document is how well its provisions address the other kind. These are accidents linked to ergonomics-related factors, which are often outside employees’ control.

A copy of the complete final rule and background documents can be found on the Federal Rail Administration web site,

Any lack of attention to ergonomics in the February 13 rule is not necessarily an indication of indifference, either in the DOT or across the railroad industry. It is clear from one expert’s view and from documents provided by the FRA that these factors are receiving significant attention.

Safety expert and ergonomist Paul Adams, Ph.D, CPE, CSP told the Ergonomics Report™ that the FRA and major railroads have been focused on assessing and improving human performance for several years. Dr. Adams is Senior Consultant at Applied Safety & Ergonomics, Inc. in Ann Arbor, Michigan. He explained that the Agency has conducted studies on human factors related to yard accidents, that the American Association of Railroads (AAR) published a study on fatigue countermeasures in 2000, and at least one Class I railroad with which he had worked has developed outstanding simulators to assess engineer performance.

The summary of the rule outlines the FRA’s main concerns and its key provisions:

Human factors are the leading cause of train accidents, accounting for 38 percent of the total in 2005. Human factors also contribute to employee injuries. This final rule establishes greater accountability on the part of railroad management for administration of railroad programs of operational tests and inspections, and greater accountability on the part of railroad supervisors and employees for compliance with those railroad operating rules that are responsible for approximately half of the train accidents related to human factors. Additionally, this final rule will supplant emergency Order 24, which requires special handling, instruction and testing of railroad operating rules pertaining to hand-operated main track switches in non-signaled territory. Finally, an appendix has been added to 49 CFR part 218 to provide guidance for remote control locomotive operations that utilize technology in aiding point protection.

The rule itself stresses that companies, supervisors and operators alike have responsibility for preventing “egregious, gross and willful violations.”

It also charges railroads to “systematically evaluate safety risks, manage those risks and implement measures to eliminate and mitigate risks in warning devices and signage at railway crossings.” Though sometimes phrased differently, it’s an instruction that appears with reference to other railroad operations throughout the document. 

Well-Documented Contributing Factors in Lapses

Factors outside employees’ control include poor ergonomic design of equipment and systems, budget cuts that result in short staffing, over-long workdays, excessive overtime, inappropriate tools and inadequate training. Employees in most industries work around problems like these every day, and there is no reason to suppose they are unknown in railroad companies. 

A derailment on November 15, 2003 in Washington illustrates several aspects of fatigue-related, operator-error accidents.
A northbound Union Pacific Railroad (UP) train struck a southbound Burlington Northern Santa Fe Railway Company (BNSF) train, derailing five cars and seriously injuring the UP crew of two. Some 2,800 gallons of fuel were released from the ruptured fuel tanks of the UP locomotives. Neither the BNSF nor the UP train crews had reported any operating difficulties or physical problems prior to the accident.

The National Transportation Safety Board (NTSB) investigation revealed that both the engineer and conductor on the UP locomotive suffered from sleep debt, as well as a higher-than-normal tendency to fall asleep because of pre-existing medical conditions. Shift patterns that forced them to invert night-time and day-time sleep patterns were also seen as significant. The report concluded that the crew members’ failure to recognize the impending collision suggests they were most likely asleep.

A Challenge

Finding a remedy for train crew fatigue could be a challenge. Dr. Adams describes it as a complex problem for the rail transport industry. “Imagine trying to schedule a work activity where the start time frequently varies by several hours on a moment’s notice due to crossing incidents, unscheduled diversions onto sidings, or other upset conditions,” he explained. “Both the start time and task duration are heavily influenced by weather and other factors beyond the control of either the employee or the employer. Further, the workstation often moves many miles through inaccessible, remote locations over the course of the shift and the worker cannot arbitrarily stop, be relieved by a fresh crew, and go home to rest.”

He said he understands that one Class I railroad has proactively amended its rules to allow crews to stop and rest for short periods when conditions permit, and that same railroad continues to research other strategies for alleviating worker fatigue. 

FRA officials involved in the formulation of the rule were unavailable for interview. The agency provided a wealth of background information instead. The officials would have been asked whether the rule was sufficient to address the factors outside employees’ control.

Pressure from Within

Considering the question, FRA Public Affairs Specialist Warren Flatau pointed out that the FDA 2007 Rail Safety Reauthorization proposal,, specifically asks Congress for the statutory authority to regulate railroad hours of service. “There are both House and Senate rail safety reauthorization bills under consideration on the Hill,” he added.

He also noted that the fatigue issue is addressed specifically in the National Rail Safety Action Plan of May 16, 2005 and two subsequent annual updates.

The issue is mentioned in the preamble, then at greater length in the body of the 2005 Plan:

Addressing Fatigue

ACTION ITEM: Accelerate research on railroad crew work history to validate
a fatigue model for possible use to improve crew scheduling

STATUS: Target date for final report August 2006
Fatigue has long been a fact of life for many railroad operating employees, given their long and often unpredictable work hours and fluctuating schedules. The hours of service law sets certain maximum on-duty periods (generally 12 hours for operating employees) and minimum off-duty periods (generally 8 hours, or if the employee has worked 12 consecutive hours, a 10-hour off-duty period is required). 

FRA knowledge of the industry’s work patterns and the developing science of fatigue mitigation, combined with certain National Transportation Safety Board investigations indicating employee fatigue as a major factor, have persuaded FRA that fatigue is very likely at least a contributing factor in a significant number of human factor accidents. To try to obtain better information on the subject, FRA revised its own accident investigation procedures in 2004 to ensure that FRA investigators collect information on employees’ sleep/rest cycles and evaluate fatigue as a factor.

Ongoing research is aimed at validating and calibrating a fatigue model that can be used to more precisely determine the role of fatigue in human factors accidents and improve crew scheduling by evaluating the potential for fatigue given actual crew management practices. When the model is properly validated, it will be made available to railroads and their employees as the foundation for developing crew scheduling practices based on the best current science.

Though the FDA refers to the rule as “final,” it appears to be evolving. The extract from the 2005 plan suggests there is pressure from within the DOT to move ergonomics up the ladder of priorities in its rules.

But there are useful rules and useless rules. Dr. Adams stresses the importance of the former. He noted that transportation companies are responding as new data become available on human performance capabilities, including performance affects stemming from interrupted sleep patterns and extended shifts. “Fatigue is an issue in trucking, air transport, as well as railroads, and each industry is looking to minimize accident risk. If the FRA initiative results in new regulations that effectively reduce accidents, then this will be a positive. If the initiative demands resources of employers without impacting safety, then everyone loses.

Sources: Federal Railroad Administration; Dr. Paul Adams; Warren Flatau

This article originally appeared in The Ergonomics Report™ on 2008-03-05.