DC Feedback: How to set the record straight if management blames you for an accident

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This month's installment deals with employees' rights to present their side of the story when management blames them for causing derailments, etc...

You have asked: What is an employee human factors accident? What rights do employees have when management blames them for railroad accidents?

The Federal Railroad Administration (FRA) defines in 49 CFR 225.5 "employee human factor" as: "any of the accident cause codes listed under 'Train Operation - Human Factors' in the current 'FRA Guide for Preparing Accident/Incident Reports,' except for those train accident cause codes pertaining to non-railroad workers. For purposes of this definition 'employee' includes the classifications of Worker on Duty - Employee, Employee not on Duty, Worker on Duty - Contractor, and Worker on Duty - Volunteer." In the "FRA Guide for Preparing Accident/Incident Reports" there are 104 separate categories listed under "Train Operation - Human Factors." These fall under broad general headings including:

All of these broad headings contain descriptions of an employee human error, which is almost always a failure to act appropriately under the operating rules according to railroad management, who use it to explain the cause of an accident. Each of the 104 human factor descriptions is assigned a number that begins with the prefix "H." For example: under the heading "Speed," code number "H604 - Train outside yard limits under clear block, excessive speed," could be used in reporting an accident by entering that code number on form F 6180.54, in field number 38 (Primary Cause Code). There is an additional field (number 39) that permits the railroad to identify a "Contributory Cause Code." The "Narrative Description" section of F 6180.54 provides an option to elaborate on the complexities of an accident, or, if no specific code fits the cause the number, may be used by classifying the cause as "H999 - Other train operation/human factors." Supplemental information is then required in the Narrative Description to explain the cause(s).

According to Chapter 8, of the Federal Railroad Administration's "Guide for Preparing Accident/Incidents:" If, in reporting a rail equipment accident/incident on form - FRA F 6180.54 (nearly all major accidents would be reported using this form) a railroad cites employee human factor as the primary cause or a contributing cause of the accident; then the railroad that cited such employee human factor must complete form FRA - F 6180.81, which is entitled, "Employee Human Factor Attachment." The Employee Human Factor Attachment is to be attached to the Rail Equipment Accident/Incident Report to which it pertains. This procedure alerts FRA to the railroad's determination that an accident was caused by an employee human factor.

It also creates a requirement to notify the employee that his or her acts, omissions, or physical condition have been determined as the cause of the accident. This notification, and the subsequent filing of FRA form - F 6180.78 - "Employee Statement Supplementing Railroad Accident Report," provides an opportunity for the employee to counter those charges.

This requirement is found in an amendment to the original Accident Reporting Act. In 49 USC, Chapter 209 Accidents and Incidents, 20901, wherein it states:

"(a) General Requirements. -- Not later than 30 days after the end of each month, a railroad carrier shall file a report with the Secretary of Transportation on all accidents and incidents resulting in injury or death to an individual or damage to equipment or a roadbed arising from the carrier's operations during the month. The report shall be under oath and shall state the nature, cause, and circumstances of each reported accident or incident. If a railroad carrier assigns human error as a cause, the report shall include, at the option of each employee whose error is alleged, a statement by the employee explaining any factors the employee alleges contributed to the accident or incident."

This provision was made to provide employees an opportunity to "tell their side of the story" and assist the Federal Railroad Administration (FRA) in its effort to determine what actually caused an accident. It stems from the fact that most accident/incident reports are prepared exclusively by the railroads and the employee, who has the most information regarding the circumstances of the accident, may provide highly significant information to improve safety.

We have learned that accidents are seldom, if ever, the result of a single cause. Dr. James Reason, Professor of Psychology at the University of Manchester, England, a noted expert on human error, states in his book, Human Error, (1990):

"In considering the human contribution to systems disasters, it is important to distinguish two kinds of error: active errors, whose effects are felt almost immediately, and latent errors, whose adverse consequences may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system's defences (see Rasmussen & Pedersen, 1984). In general, active errors are associated with the performance of the 'front-line' operators of a complex system: pilots, air traffic controllers, ships' officers, control room crews and the like. Latent errors, on the other hand, are most likely to be spawned by those whose activities are removed in both time and space from the direct control interface: designers, high-level decision makers, construction workers, managers and maintenance personnel."

Dr. Reason continues to explain that recent accidents (such as Three Mile Island, Bhopal, Chernobyl, and the Challenger explosion) have, "made it increasingly apparent that latent errors pose the greatest threat to the safety of a complex system." In Human Error, page 173, he continues by saying:

"In the past, reliability analyses and accident investigations have focused primarily upon active operator errors and equipment failures. While operators can, and frequently do, make errors in their attempts to recover from an out-of-tolerance system state, many of the root causes of the emergency were usually present within the system long before these active errors were committed.

"Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking."

Similar latent errors have been identified by the National Transportation Safety Board (NTSB) in the rail and transit industry. Most notably, the February 1, 1996, runaway at Cajon Pass on the Burlington Northern Santa Fe, and the January 6, 1996, failure of a computerized braking system on the Washington D.C. Metro, which took the life of the train's operator.

Knowing that many accidents in the railroad workplace are not always the exclusive result of an "active error" -- but may be caused by "latent errors" -- is little comfort to railroad employees who always shoulder the blame. It is, in part, a problem with the existing system of reporting accidents/incidents. The FRA form F 6180.54, assumes there is a single "Primary Cause" of an accident and perhaps one "Contributory Cause." The modern, scientific literature on accidents does not support such single causes of accidents, however. That is why it is so important to include an employee's assessment.

A classic example, that we as engineers can all relate to, could involve an accident from overspeed, in CTC territory, at a slow track condition, where the engineer has had the first opportunity to use the locomotive and train's braking system. FRA Form 6180.54 may show human error code, "H604 - Train outside yard limits under clear block, excessive speed," as the Primary Cause Code of the accident. The reality may be that the engineer may have had a locomotive consist with only the lead locomotive's dynamic brake operating and all trailing unit dynamic brakes inoperative. Most of you have been in a similar situation -- you have no means to monitor the effectiveness of the trailing locomotive's dynamic braking, and possibly no reports of any dynamic brake failures; the result is to be unable to control train speed as you would otherwise predict. Compounding the problem may be the absence of advance warning signs for the slow track condition, incomplete or erroneous train consist information, unfavorable weather conditions, fatigue, and the list goes on. These could be classified as "Contributory Causes" and even "latent errors" within the system. Unfortunately these are seldom reported on F 6180.54. As discussed above, Form F6180.78, Part II, "Employee Statement Supplementing Railroad Accident Report" gives you the opportunity to include this type of information.

The requirements for filing are found in 49 CFR part 225, 225.12. Generally, they provide that:

The use of FRA F 6180.78, gives railroad employees an opportunity to solve many of the underlying problems we face in the complex railroad environment. Our self-managed role has required us to assume a tremendous amount of responsibility without a corresponding authority to change the unsafe conditions we encounter.

If we cannot change those conditions directly, it is possible to complete the record so that others may know when change is needed.

2000 Brotherhood of Locomotive Engineers