United States Department of Transportation
i
Switching operations fatality analysis : findings and recommendations of the SOFA working group
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1999-10-01
[PDF-360.18 KB]
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Abstract:On February 1998, a Switching Operations Fatality Analysis (SOFA) Working Group (WG) was formed at the request of the Federal Railroad Administration (FRA) to review recent fatal incidents and develop recommendations for reducing fatalities in switching operations The Working Group developed a codified database of standardized information, referred to as the 'SOFA Matrix' from the wide range of information in the 76 FRA fatal accident case files between January 1992 and July of 1998. In addition, the group reviewed very limited data obtained from FRA files concerning employee fatalities (FEs) from 1975 to 1991. This database, along with expertise capturing exercises, were then used to generate trends or patterns in the data for a more comprehensive understanding of the fatalities they were investigating. The incident reports generally tried to establish a single probable cause of each switching incident. However, the WG concluded that fatalities more often resulted from the coming together of a complex set of factors. The report presents the WG's five major findings, along with recommendations for improving safety of switching operations and a brief discussion of the context and rationale for each recommendation. The five findings/recommendations involve securing the equipment, work on the same or adjacent track(s), job safety briefings, communication between the locomotive engineer and the train crew, and crew member experience. With respect to incident investigation and analysis, the WG made four specific recommendations to the FRA: establish and maintain a database of objective FE data, provide computer support to the data collection process, continue review and monitoring of fatal accident data, and modify the data collection process to include a team concept. A fatal incident investigation protocol is outlined.
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