Technical Reports

Human Factors Root Cause Analysis of Accidents/Incidents Involving Remote Control Locomotive Operations

  • 01
  • May
  • 2006
AUTHOR: Stephen Reinach and Alex Viale
OFFICE: RPD
REPORT NUMBER: DOT/FRA/ORD-06/05
KEYWORDS: Remote control locomotive operations, portable locomotive control, railroad safety, remote
ABSTRACT: This report presents findings from a human factors root cause analysis (RCA) of six train accidents/incidents—collisions, derailments, and employee injuries—that involved remote control locomotive (RCL) operations in U.S. railroad switching yards. Descriptive data from participating railroads were collected on all Federal Railroad Administration reportable RCL accidents/incidents from May 1 to October 31, 2004. RCA were performed on six RCL accidents/incidents (case studies) to examine some of the factors that contributed to the events in further detail. 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. HFACS-RR identifies 23 unique categories of accident/incident contributing factors among five different levels of a system. Participating railroads reported a total of 67 RCL accidents/incidents: 29 collisions, 25 derailments, and 13 employee injuries. RCA were conducted on three collisions, two derailments, and one employee injury. A total of 36 probable contributing factors were identified among the 6 RCA, and 33 of these were concentrated among 6 HFACS-RR categories: technological environment (8), skill-based errors (7), the organizational process (6), inadequate supervision (5), decision errors (4), and resource management (3). Loss of remote control operator (RCO) situation awareness was a significant factor in five of the six accidents/incidents. Based on an analysis of all of the contributing factors, several key safety issues emerged: loss of RCO 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. This report suggests recommendations for future research to enhance RCL operations safety.
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