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2006 railroad employee fatalities : case studies and analysis
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  • Abstract:
    This document, entitled “2006 Railroad Employee Fatalities: Case Studies and Analysis,” was

    developed to promote and enhance awareness of many unsafe behaviors and conditions that

    typically contribute to railroad employee fatalities, and is intended to assist railroad industry stakeholders in their efforts to prevent similar tragedies. This document contains the following materials: Narrative reports which provide in-depth coverage of 2006's railroad employee fatalities, helping readers to visualize the accident scene and chain of events leading up to the fatalities, and the post-accident investigation process; Summaries, preceding each narrative report, which highlight important elements of each individual fatality, particularly the possible contributing factors (PCFs). This format allows the reader to walk through and analyze each fatality scenario, identifying ways the fatalities could have been prevented. PCFs are expressed as brief narrative statements such as “The rail cars that struck the Conductor were set in motion by a mismatch coupling.” The summaries also list Selected Factors which identify where and when the individual fatalities occurred, particulars about the fatally injured parties (i.e. age, years of service, training, and certification where applicable), craft and positions of the other workers, and major activities of fatally injured employees at the time of the incidents; Overall findings for the 2006 fatalities (see Pages 2-7) which identify who the majority of fatally injured employees were (i.e. craft, job position, age group, and years of service); what most were doing at the time of the incidents; when most were fatally injured (i.e. time of year and time of day); where most incidents occurred (i.e. type of railroad); and most importantly, why most fatalities occurred in terms of PCFs; and Bar and pie charts (Appendices A through I) which illustrate the above findings.

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