United States Department of Transportation
i
Human Factors Root Cause Analysis of Accident/Incidents Involving Remote Control Locomotive Operations [Research Results]
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2005-04-01
[PDF-522.93 KB]
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Abstract:The Federal Railroad Administration (FRA) Office of Research and Development sponsored a project to learn more about human factors root cause analysis (RCA) of six train accidents/incidents - collisions, derailments, and employee injuries - involving remote control locomotive (RCL) operations in U.S. railroad switching yards. Descriptive data from participating railroads were collected on all FRA reportable RCL accidents/incidents from May to October 2004. RCA were performed on six RCL accidents/incidents (case studies) to examine factors that contributed to each accident/incident. RCA data collection and analysis tools were developed based on a modified version of the Human Factors Analysis and Classification System (HFACS-RR) to provide a theoretical foundation to the RCA. A total of 67 RCL accidents/incidents were reported by participating railroads: 29 collisions, 25 derailments, and 13 employee injuries. RCA were conducted on three collisions, two derailments and one injury. A total of 36 probable contributing factors were identified among the six case studies, and 33 of these were concentrated among six HFACS-RR categories: the technological environment (8), skill-based errors (7), the organizational process (6), inadequate supervision (5), decision errors (4), and resource management (3). Based on an analysis of all of the contributing factors, several key safety issues emerged: loss of remote control operator (RCO – Figure 1) situation awareness, insufficient training, inadequate staffing and pairing of inexperienced crewmembers, and inadequate practices and procedures governing RCL operations and the use of RCL technology, including pullback protection.
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