Rail Safety
The Federal Railroad Administration Is Taking Steps to Better Target Its Oversight, but Assessment of Results Is Needed to Determine Impact Gao ID: GAO-07-149 January 26, 2007Since 1980, the train accident rate has improved significantly, but progress has leveled off over the past 10 years. Recent serious accidents--such as one in Graniteville, South Carolina, that led to 9 deaths and 292 injuries--elevated concerns. The Federal Railroad Administration (FRA) develops safety standards and inspects and enforces railroads' compliance with these standards. This report addresses how FRA (1) focuses its efforts on the highest priority risks related to train accidents in planning its oversight, (2) identifies safety problems on railroad systems in carrying out its oversight, and (3) assesses the impact of its oversight efforts on safety. To complete this work, GAO reviewed FRA regulations, planning and policy documents, and safety data. GAO also contacted FRA officials in headquarters and three regional offices and others.
In planning its safety oversight, FRA is focusing its efforts on the highest priority risks related to train accidents through initiatives aimed at addressing their main causes--human behaviors and defective track--as well as through improvements in its inspection planning approach. In its May 2005 National Rail Safety Action Plan, the overall strategy for targeting its oversight at the greatest risks, FRA provides a reasonable framework for guiding these efforts. Its initiatives to address the most common causes of accidents are promising, although the success of many of them will depend on voluntary actions by the railroads. In addition, the action plan outlined the agency's development of a new inspection planning approach. Under this approach, inspectors focus their efforts on locations that data-driven models indicate are most likely to have safety problems. In carrying out its safety oversight, FRA identifies a range of specific and broad-scale safety problems on railroad systems mainly by determining whether operating practices, track, and equipment are in compliance with minimum safety standards. However, FRA is able to inspect only about 0.2 percent of railroads' operations each year and its inspections do not examine how railroads are managing safety risks throughout their systems that could lead to accidents. Such an approach, as a supplement to traditional compliance inspections, is used in the oversight of U.S. commuter railroads and pipelines and of Canadian railroads. While this type of approach can provide additional assurance of safety, GAO is not recommending that FRA adopt it because its various initiatives to reduce the train accident rate have not yet had time to demonstrate their effects on safety. FRA uses a broad range of goals and measures to assess the impact of its oversight. For example, it has developed (1) new goals to target its inspection and enforcement programs at reducing various types of railroad accidents and (2) related measures to monitor its progress. These measures include the rate of train accidents caused by human behaviors, track defects, and equipment defects. However, FRA's ability to make informed decisions about these programs is limited because it lacks measures of their direct results, such as the correction of identified safety problems. Furthermore, FRA has not evaluated the effectiveness of its enforcement program.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
January 2007:
Rail Safety:
The Federal Railroad Administration Is Taking Steps to Better Target
Its Oversight, but Assessment of Results Is Needed to Determine Impact:
GAO-07-149:
GAO Highlights:
Highlights of GAO-07-149, a report to congressional committees
Why GAO Did This Study:
Since 1980, the train accident rate has improved significantly, but
progress has leveled off over the past 10 years. Recent serious
accidents”such as one in Graniteville, South Carolina, that led to 9
deaths and 292 injuries”elevated concerns. The Federal Railroad
Administration (FRA) develops safety standards and inspects and
enforces railroads‘ compliance with these standards.
This report addresses how FRA (1) focuses its efforts on the highest
priority risks related to train accidents in planning its oversight,
(2) identifies safety problems on railroad systems in carrying out its
oversight, and (3) assesses the impact of its oversight efforts on
safety. To complete this work, GAO reviewed FRA regulations, planning
and policy documents, and safety data. GAO also contacted FRA officials
in headquarters and three regional offices and others.
What GAO Found:
In planning its safety oversight, FRA is focusing its efforts on the
highest priority risks related to train accidents through initiatives
aimed at addressing their main causes”human behaviors and defective
track”as well as through improvements in its inspection planning
approach. In its May 2005 National Rail Safety Action Plan, the overall
strategy for targeting its oversight at the greatest risks, FRA
provides a reasonable framework for guiding these efforts. Its
initiatives to address the most common causes of accidents are
promising, although the success of many of them will depend on
voluntary actions by the railroads. In addition, the action plan
outlined the agency‘s development of a new inspection planning
approach. Under this approach, inspectors focus their efforts on
locations that data-driven models indicate are most likely to have
safety problems.
In carrying out its safety oversight, FRA identifies a range of
specific and broad-scale safety problems on railroad systems mainly by
determining whether operating practices, track, and equipment are in
compliance with minimum safety standards. However, FRA is able to
inspect only about 0.2 percent of railroads‘ operations each year and
its inspections do not examine how railroads are managing safety risks
throughout their systems that could lead to accidents. Such an
approach, as a supplement to traditional compliance inspections, is
used in the oversight of U.S. commuter railroads and pipelines and of
Canadian railroads. While this type of approach can provide additional
assurance of safety, GAO is not recommending that FRA adopt it because
its various initiatives to reduce the train accident rate have not yet
had time to demonstrate their effects on safety.
FRA uses a broad range of goals and measures to assess the impact of
its oversight. For example, it has developed (1) new goals to target
its inspection and enforcement programs at reducing various types of
railroad accidents and (2) related measures to monitor its progress.
These measures include the rate of train accidents caused by human
behaviors, track defects, and equipment defects. However, FRA‘s ability
to make informed decisions about these programs is limited because it
lacks measures of their direct results, such as the correction of
identified safety problems. Furthermore, FRA has not evaluated the
effectiveness of its enforcement program.
Figure: Track Inspector Examining Rail to Assess Its Safety Compliance:
[See PDF for Image]
Source: FRA.
[End of Figure]
What GAO Recommends:
GAO is recommending that FRA develop measures of the direct results of
its oversight and evaluate the effectiveness of its enforcement
program. The Department of Transportation did not provide overall
comments on these recommendations but did provide several technical
comments, which were incorporated as appropriate.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-149].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Katherine Siggerud at
(202) 512-2834 or siggerudk@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
FRA Has Made Progress in Targeting Its Oversight Efforts on the Basis
of Risk:
FRA Relies Primarily on Direct Inspections to Identify Safety Problems
and Does Not Oversee Railroads' Management of Safety Risks:
FRA Measures Its Progress in Achieving a Variety of Safety Goals, but
Has Limited Information on the Direct Results of Its Oversight:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Other Aspects of Our Work:
Appendix II: FRA Addresses Safety Problems through Cooperation and
Enforcement:
Appendix III: Oversight of Risk Management in the U.S. Commuter
Railroad, U.S. Pipeline, and Canadian Railroad Industries:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: FRA's Inspection Disciplines:
Table 2: Key FRA Initiatives Aimed at Addressing Main Causes of Train
Accidents:
Table 3: FRA's Safety Performance Measures:
Table 4: Description of FRA Enforcement Actions and Frequency of Use,
January 2005 through July 2006:
Table 5: Risk Management Framework:
Figures:
Figure 1: Train Accident Rates, 1980 through 2005:
Figure 2: Train Miles Traveled, 1996 through 2005:
Figure 3: Train Injuries and Deaths, 1980 through 2005:
Figure 4: Primary Causes of Train Accidents, 2005:
Figure 5: Human Factor and Track Accident Rates, 1980 through 2005:
Figure 6: FRA Inspector Measuring Track Gauge:
Figure 7: FRA Inspector Inspecting Train Cars:
Figure 8: Inspections Conducted and Defects and Violations Cited, by
Inspection Discipline, in 2005:
Figure 9: How FRA's Inspection and Enforcement Programs Contribute to
Rail Safety:
Figure 10: FRA's Civil Penalties, 1996 through 2005, in 2005 Dollars:
Abbreviations:
APTA: American Public Transportation Association:
FRA: Federal Railroad Administration:
NTSB: National Transportation Safety Board:
PHMSA: Pipeline and Hazardous Materials Safety Administration:
United States Government Accountability Office:
Washington, DC 20548:
January 26, 2007:
The Honorable Patty Murray:
Chairman:
The Honorable Christopher Bond:
Ranking Minority Member:
Subcommittee on Transportation, Housing and Urban Development, and
Related Agencies:
Committee on Appropriations:
United States Senate:
The Honorable John Olver:
Chairman:
The Honorable Joe Knollenberg:
Ranking Minority Member:
Subcommittee on Transportation, Housing and Urban Development, and
Related Agencies:
Committee on Appropriations:
House of Representatives:
Since 1980, the overall safety record in the railroad industry, as
measured by the rate of train accidents, has improved markedly. (See
fig. 1.) However, during the past decade, the rate of improvement has
leveled off, and a number of serious accidents in 2004 and 2005
elevated concerns about railroad safety. For example, in January 2005,
a train carrying hazardous materials collided with a standing train in
Graniteville, South Carolina, resulting in 9 deaths and 292 injuries
and requiring the evacuation of 5,400 people. In response to the
leveling off of the train accident rate, this accident, and other
serious train accidents, in May 2005, the federal railroad safety
regulator, the Federal Railroad Administration (FRA), announced a
National Rail Safety Action Plan to improve its safety oversight. The
plan outlines strategies for FRA to target the most frequent, highest-
risk causes of accidents, focus federal oversight and inspection
resources, and research the use of technologies in order to improve
rail safety.
Figure 1: Train Accident Rates, 1980 through 2005:
[See PDF for image]
Source: FRA.
[End of figure]
Citing concerns over several serious accidents that occurred in 2005,
the Senate Appropriations Committee directed that we assess FRA's
oversight approach. Accordingly, this report concentrates on how FRA
(1) focuses its efforts on the highest priority risks related to train
accidents in planning its safety oversight, (2) identifies safety
problems on railroad systems in carrying out its oversight, and (3)
assesses the impact of its oversight efforts on safety.
To determine how FRA focuses its efforts on the highest priority risks
related to train accidents in planning its safety oversight, we
reviewed the agency's National Rail Safety Action Plan, plans for
developing new regulations, inspection planning documents, and other
key planning documents related to targeting its oversight at these
risks. We also discussed oversight planning efforts with FRA officials.
To assess how FRA identifies safety problems on railroad systems in
carrying out its oversight, we reviewed FRA's statutory authority;
regulations; and policies, procedures, and guidance for conducting
inspections and identifying safety issues. We reviewed data from FRA on
its inspection activities for the period from 1996 through 2005. We
also examined risk management principles and safety oversight
approaches used by other modal administrations within the Department of
Transportation and elsewhere that have similar safety missions in order
to determine their possible application to FRA. To determine how FRA
assesses the impact of its oversight efforts on safety, we examined FRA
safety performance measures and evaluations of its oversight
activities, determined how FRA uses this information in making
decisions about its oversight, and reviewed our products on performance
measurement and evaluation.
As part of our work in each of these areas, we interviewed program and
enforcement officials at FRA headquarters, as well as at three regional
offices covering states with the highest train accident rates. We also
discussed FRA's approach to safety oversight with representatives of
railroads, unions, and state railroad safety organizations. Our work
focused on FRA oversight efforts to reduce the rate of train accidents
rather than those to reduce highway-rail crossing and trespassing
accidents because (1) the Department of Transportation's Inspector
General has recently assessed efforts to reduce highway-rail crossing
accidents[Footnote 1] and (2) trespassing accidents primarily involve
issues not related to railroad safety performance. We also focused on
FRA's oversight of railroads rather than its oversight of nonrailroad
companies (such as shippers of hazardous materials by rail) because the
agency's oversight efforts focus primarily on railroads. In addition,
according to FRA, most recent serious train accidents involving the
release of hazardous materials have resulted from problems with
railroad operations. As part of our review, we assessed internal
controls and the reliability of FRA's data on its inspection activities
and enforcement actions that were pertinent to these efforts. We
determined that the data elements were sufficiently reliable for our
purposes. We conducted our work from November 2005 through January 2007
in accordance with generally accepted government auditing standards.
(See app. I for additional information on our scope and methodology.)
Results in Brief:
In planning its safety oversight, FRA is focusing its efforts on the
highest priority risks related to train accidents through various
initiatives aimed at addressing the main causes of these accidents as
well as through improvements in its inspection planning approach. The
agency's overall strategy for targeting its oversight at the greatest
risks is the National Rail Safety Action Plan. This plan provides a
reasonable framework for guiding the agency's efforts to improve its
oversight. It includes initiatives to address the two main causes of
train accidents--human factors and defective track--and FRA has pursued
some additional initiatives to address these causes since issuing the
plan.[Footnote 2] These initiatives--which include new regulations,
research on new technologies and approaches for improving safety, and
new vehicles for inspecting track--have the potential to reduce the
risks associated with these causes and thereby reduce the rate of train
accidents. For example, FRA has recently issued proposed regulations
that, if finalized, will enable the agency to take enforcement actions
when railroad employees do not follow key railroad operating procedures
for ensuring safety and, therefore, may help to reduce some common
types of accidents caused by human factors. However, most of these
initiatives have not yet been fully implemented, and, while some may
start showing results in the next year or two, their overall impact on
safety will probably not be apparent for a number of years.
Furthermore, the ability of many of these efforts to improve safety
will depend on voluntary actions by railroads, such as the adoption of
a model FRA has developed to improve train crew scheduling practices in
order to prevent worker fatigue. In addition, the National Rail Safety
Action Plan announced a new approach for planning inspections that
relies on greater use of accident and inspection data and other data.
Under this approach, which FRA has been using for over a year,
inspectors focus their efforts on locations that, according to data-
driven models, are likely to have safety problems. This new planning
approach allows FRA to use its inspectors more effectively and better
target the greatest safety risks.
In carrying out its safety oversight, FRA identifies safety problems on
railroad systems mainly through routine inspections that determine
whether operating practices, track, and equipment, such as signals and
locomotives, are in compliance with safety standards. Through this
approach, FRA inspectors identify a range of safety problems at various
sites on railroads' systems. FRA also identifies some broad-scale
problems that affect multiple sites, primarily through analyses of
accident and inspection data, internal discussions, and some nonroutine
inspections. However, the number of FRA and state inspectors is small
relative to the size of the industry and FRA inspections are able to
cover only about 0.2 percent of railroads' operations each
year.[Footnote 3] Also, these inspections focus on compliance with
minimum standards and are not designed to determine how well railroads
are managing safety risks throughout their systems that could lead to
accidents. The American Public Transportation Association (APTA), the
Pipeline and Hazardous Materials Safety Administration (PHMSA), and
Transport Canada have implemented approaches to oversee the management
of safety risks by U.S. commuter railroads, U.S. pipelines, and
Canadian railroads, respectively. Risk management can be described as a
continuous process of managing--through the systematic identification,
analysis, and control of risks associated with safety hazards (such as
train collisions)--the likelihood of hazards' occurrence and their
negative impact.[Footnote 4] These oversight approaches complement,
rather than replace, traditional compliance inspections and, therefore,
provide additional assurance of safety. However, because we believe
that FRA's initiatives to reduce train accident rates need time to
mature and demonstrate their effects on safety, we are not recommending
that FRA adopt an approach for overseeing railroads' management of
safety risks.
FRA uses a broad range of goals and measures to assess the impact of
its oversight efforts on safety. For example, it has developed new
goals to target its inspection and enforcement efforts at reducing
various types of railroad accidents and related measures to track its
progress. These measures include the level of train accidents caused by
human factors, track defects, and equipment defects, both nationwide
and within each of its eight regions. These safety performance measures
provide FRA with much information that it uses to make decisions about
its oversight approach. However, its ability to make informed decisions
is limited because it lacks measures of the direct results of its
inspection and enforcement programs, such as measures of the extent to
which these programs have resulted in the correction of identified
safety problems or improvements in compliance. We have found that it is
a useful practice for agencies to establish measures of programs'
direct results to help show their contributions to the ultimate results
the agencies seek to achieve. Furthermore, while FRA has made some
changes in its oversight approach in response to external and internal
evaluations, the agency has not evaluated the effectiveness of its
enforcement program in achieving desired results. Evaluations can
provide a broader range of information on program performance and how
to improve it than performance measures alone. Both performance
measures and evaluations can provide valuable information on program
results that helps hold agencies accountable for the performance of
their programs.
To improve FRA's ability to determine the extent to which its
inspection and enforcement programs are contributing to rail safety and
whether changes in these programs are needed, we are recommending that
FRA develop and implement measures of the direct results of its
inspection and enforcement programs and evaluate its enforcement
program. We provided a draft of this report to the Department of
Transportation for its review and comment. The department did not offer
overall comments on the draft report or its recommendations. It did
offer several technical comments, which we incorporated where
appropriate.
Background:
Railroads are an important component of the transportation system,
transporting about 42 percent of the nation's freight (as measured by
weight). For passenger movement, railroads play a much smaller role
than do highway and air travel; however, communities are looking to
different forms of public transit for relief, particularly as highways
become increasingly congested. Demand continues to grow for both
freight and passenger transportation on railroads. In 2005, railroads
traversed 790 million train miles,[Footnote 5] an increase of 18
percent since 1996. (See fig. 2.) Moreover, the Department of
Transportation estimates that between 1998 and 2020, the amount of
freight transported by rail (as measured by weight) will increase by
about 50 percent. Commuter and intercity passenger railroads have also
grown--providing over 522 million passenger trips in 2005, compared
with 385 million in 1995. According to the Federal Transit
Administration, as of 2006, seven more commuter rail systems throughout
the country were being planned or designed.
Figure 2: Train Miles Traveled, 1996 through 2005:
[See PDF for image]
Source: FRA.
[End of figure]
The railroad industry is primarily composed of 7 large freight
railroads (called Class I railroads); about 560 smaller freight
railroads (called Class II and III railroads); and 118 passenger,
commuter, tourist, excursion, and other railroads.[Footnote 6] Within
the industry, Class I freight railroads predominate, representing about
93 percent of railroad freight revenue and 69 percent of the total U.S.
rail mileage. Class II and Class III railroads include a number of
regional and short line railroads that provide freight transportation.
Class II regional railroads typically operate 400 to 650 miles of track
in a region spanning two to four states, whereas Class III short lines
typically perform point-to-point service over short distances.
On average, about 446 people have been injured and 14 people have been
killed each year over the past decade, from 1996 through 2005,
exclusive of highway-railroad grade crossing and trespassing accidents.
Despite overall improvements since 1980, gains have tapered off. Since
1992, the accident rate has remained at about or sometimes more than
four accidents per million train miles. (See fig. 1.) In recent years,
a number of serious accidents raised concerns about the level of safety
in the railroad industry. Train accidents resulted in 1,884 injuries
and 15 deaths in 2002, and 733 injuries and 33 deaths in 2005. (See
fig. 3.) FRA officials attributed the large rise in number of injuries
and deaths in 2002, and subsequently in 2005, to one or two major
accidents, as opposed to a series of accidents. For example, in 2002, a
derailment in Minot, North Dakota, led to the release of approximately
200,000 gallons of anhydrous ammonia, 1,442 injuries and 1 death. In
2005, a train collision in Graniteville, South Carolina, resulted in
the evacuation of 5,400 people, 292 injuries and 9 deaths.
Figure 3: Train Injuries and Deaths, 1980 through 2005:
[See PDF for image]
Source: FRA.
Note: Injuries were far more common than deaths during the period of
1980 through 2005; deaths ranged from 4 to 67 per year. Figures do not
include highway-railroad crossing and trespassing incidents.
[End of figure]
Although Class I railroads have a lower rate of accidents than Class II
and III railroads, because of their size, they account for most train
accidents; in 2005, Class I railroads were involved in 76 percent of
train accidents.[Footnote 7] Moreover, Class I railroads were involved
in 53 percent of injuries and 58 percent of deaths during that year.
According to FRA data, the majority of train accidents are attributable
to either human factors or track defects. (See fig. 4.) For 2005, FRA
data show that human factors and track defects were the primary causes
of 72 percent of all train accidents. Those accidents caused by human
factors often result from actions such as improperly positioning
switches, shoving cars without properly checking for safe conditions,
leaving cars in a position that obstructs track, and failing to secure
a sufficient number of handbrakes. Those accidents caused by defective
track often result from defective or ineffective crossties; broken or
worn switch points; and broken, fissured or fractured rail components.
Figure 4: Primary Causes of Train Accidents, 2005:
[See PDF for image]
Source: GAO analysis of FRA data.
[A] Interaction of lateral and vertical forces refers to a specific
type of accident that occurs when a lateral, or sideways, force exceeds
a vertical force, or gravity, by 50 percent or more. Lateral force may
be caused by travel through curves and alignment imperfections in the
track.
[B] The miscellaneous category of accident causes contains a number of
subcategories, none of which exceeds 1.5 percent.
[End of figure]
As have overall accident rates, improvements in human factor and track
accident rates have leveled off over the past decade, achieving their
lowest rates in 1996 and 1995, respectively. (See fig. 5.) According to
FRA, the increase in the human factor accident rate in 2004 can be
attributed to increases in accidents caused by employees not following
railroad operating rules. (These rules specify various operating
procedures, such as the proper positioning of track switches, to ensure
safe operations.) However, according to FRA, these types of human
factor accidents decreased by 21 percent from the first half of 2005 to
the first half of 2006. Officials attribute this decrease largely to
actions the agency has taken to focus railroads' attention on this
problem,[Footnote 8] including issuing a safety advisory and an
emergency order in 2005 to address the problem of employees leaving
hand-operated main track switches in nonsignaled territory in the wrong
position, the cause of an increasing number of accidents, including the
Graniteville accident.[Footnote 9]
Figure 5: Human Factor and Track Accident Rates, 1980 through 2005:
[See PDF for image]
Source: FRA.
[End of figure]
While the individual railroads have primary responsibility for their
safe operation, FRA conducts various activities to oversee safety. FRA
develops and enforces regulations for the industry that include
requirements related to safety. For example, these regulations include
requirements governing track, signal and train control systems, grade
crossing warning device systems, mechanical equipment--such as
locomotives and tank cars--and railroad operating practices. FRA also
enforces hazardous materials regulations issued by PHMSA as they relate
to the safe transportation of such materials by rail. Many of FRA's
regulations have detailed, prescriptive minimum requirements for track
and equipment, such as wheel safety requirements and formulas that
determine maximum allowable speeds on curved track. However, some
regulations are not prescriptive and allow railroads greater
flexibility in determining how to comply. For example, if a railroad
chooses to implement a processor-based train control system or
product,[Footnote 10] it must develop and receive FRA's approval for a
railroad safety program plan. The plan should include a description of
risk assessment procedures and the safety assessment process, and
railroads have flexibility to adjust their programs to accommodate the
specific system or product change. In addition, some regulations
require railroads to develop and implement safety programs, such as
accident and incident reporting programs and roadway worker protection
programs.
In 1996, FRA adopted a more participatory approach to rulemaking
through the creation of the Railroad Safety Advisory Committee. This
committee is designed to include all segments of the rail community in
developing solutions to safety regulatory issues. Currently, the
committee consists of 39 member organizations, including
representatives from railroads, railroad associations, labor, states,
and agencies with railroad regulatory responsibility in Canada and
Mexico.
FRA conducts inspections to determine railroads' compliance with its
regulations. Typically, inspectors conduct inspections at specific
sites of railroad operations. For example, inspectors examine track,
equipment, devices, employee actions, or procedures and may review
records maintained by the railroad in order to determine the railroad's
compliance with FRA regulations. Inspectors generally specialize in one
of five areas, called inspection disciplines: (1) operating practices,
(2) track, (3) hazardous materials, (4) signal and train control, and
(5) motive power and equipment. (See table 1.) FRA's policy is to cite
defects for most instances of noncompliance and to encourage the
railroad to comply voluntarily.
Table 1: FRA's Inspection Disciplines:
Inspection Discipline: Operating practices;
Examples of what inspections cover (not all inclusive): Railroad
operations related to human factors, including employee compliance with
railroad operating rules, railroads' monitoring of this compliance,
drug and alcohol testing of employees, employees' hours of service,
radio communications, locomotive engineer qualification, and accident
and incident reporting.
Inspection Discipline: Track and structures[A];
Examples of what inspections cover (not all inclusive): Condition of
track and structures, including track components and geometry, railroad
track inspections, and programs to maintain continuous welded rail
track and protect roadway workers.
Inspection Discipline: Hazardous materials;
Examples of what inspections cover (not all inclusive): Rail
transportation of hazardous materials, including the integrity,
markings, maintenance, and placement of tank cars; the training of
train crews; security; and emergency preparedness.
Inspection Discipline: Signal and train control;
Examples of what inspections cover (not all inclusive): Signal
switching systems, locomotive signal devices, locks and brake
application, including related recordkeeping, testing, modifications,
and repairs.
Inspection Discipline: Motive power and equipment;
Examples of what inspections cover (not all inclusive): Design and
operation of railroad rolling equipment, including railroad freight and
passenger car safety, locomotive safety and maintenance, safety
devices, brake system safety, and emergency preparedness procedures.
Source: GAO analysis of FRA information.
Notes: FRA has recently established a new inspection discipline,
industrial hygiene, which covers the protection of railroad employees
on the job, including enforcement of FRA standards for occupational
safety and health. The discipline is also responsible for the operation
of FRA's internal occupational safety and health program for ensuring
FRA employee safety and health. The resources devoted to this
inspection discipline are relatively small--FRA plans to have a total
of 5 industrial hygienist inspectors. In comparison, the other
inspection disciplines each have between 50 and 90 inspectors,
approximately.
[A] In addition to its manual inspections, FRA has an automated track
inspection program that uses data produced by vehicles that precisely
measure track geometry.
[End of table]
When railroads do not comply voluntarily or identified defects are
serious, FRA may cite violations and assess civil penalties either
against railroads or individuals or take other enforcement actions to
promote compliance with its regulations. FRA developed the concept of
focused enforcement in the mid-1990s to ensure that inspectors know
which violations pose the greatest hazards and make enforcement
decisions accordingly. The purpose of this approach is to concentrate
FRA's enforcement efforts on the areas with the greatest potential
safety benefits. FRA's enforcement policy, as stated in its
regulations, specifies that before recommending penalties, inspectors
should consider the seriousness of the condition or act, the potential
safety hazards, and the current level of compliance of the individual
or railroad, among other things. FRA is authorized to negotiate civil
penalties with railroads and exercises this authority. For example, it
settles claims annually with each Class I railroad. FRA uses civil
penalties as its primary enforcement tool. However, it also has other
available enforcement tools. These include compliance agreements and
compliance orders, special notices for repair, emergency orders,
criminal penalties, disqualification orders and injunctions. (See app.
II for further discussion.)
FRA conducts additional oversight of Class I railroads through the
Railroad System Oversight program, established in October 2005, which
addresses safety issues not subject to regulation, such as aspects of
worker fatigue, as well as safety compliance issues. Under this
program, the agency assigns an FRA manager for each Class I railroad to
cooperate with it on identifying and resolving safety issues. These
managers act as liaisons with the railroads and labor officials,
analyze accident and inspection data for their assigned railroad, and
support FRA's inspection and enforcement efforts. Finally, under this
program, FRA has begun annual meetings with the leadership of each
Class I railroad to discuss its safety performance.
The Railroad System Oversight program replaced FRA's Safety Assurance
and Compliance Program, which had emphasized using teams--consisting of
FRA inspectors and other FRA officials, railroad officials, and union
representatives--to identify and resolve safety issues, as a complement
to FRA's regular inspection activity. The agency envisioned this
program as a comprehensive approach to safety through which these
representatives would work together to identify and correct the root
causes of problems across an entire railroad. According to FRA, the
program had a number of accomplishments, such as improving
collaboration among management, labor and FRA, and encouraging
railroads' voluntary cooperation in taking corrective action on safety
issues not covered under FRA's safety regulations. However, FRA ended
this program in response to concerns that it had lost its
effectiveness, inhibited enforcement actions, and shifted regional
resources away from conducting site-specific inspections, the mainstay
of FRA's safety program.
In addition to these activities, FRA conducts other types of safety
oversight aimed at reducing train accidents, such as monitoring of
railroad safety data, accident investigations and reviews and
investigations of complaints, and education efforts aimed at small
railroads.[Footnote 11] Furthermore, FRA funds research and development
that supports its safety oversight, by, for example, assisting in the
development of new regulations and the revision of existing
regulations.
FRA is a small agency, especially in relation to the industry it
regulates. As of July 2006, FRA had 657 full-time and part-time safety
staff, including about 400 inspectors in the field (in its regional,
district, and local offices). In addition, 30 state oversight agencies
participate in a partnership program with FRA to conduct safety
oversight activities at railroads' operating sites. Currently, about
160 state inspectors work with FRA to conduct inspections and other
investigative and surveillance activities as needed. In contrast, the
railroad industry has about 235,000 employees,[Footnote 12] 219,000
miles of track in operation, 158,000 signals and switches, and over 1.6
million locomotives and cars.
FRA Has Made Progress in Targeting Its Oversight Efforts on the Basis
of Risk:
In planning its safety oversight, FRA focuses its efforts on the
highest priority risks related to train accidents through a number of
initiatives aimed at addressing the main causes of these accidents as
well as through improvements in its inspection planning approach. The
agency's overall strategy for targeting its oversight at the greatest
risks--the National Rail Safety Action Plan--provides a reasonable
framework for guiding the agency's efforts. FRA's various initiatives
to address the two main causes of train accidents--human factors and
defective track--are promising. However, most of these initiatives are
not yet fully implemented and their overall impact on safety will
probably not be apparent for a number of years. FRA has also recently
implemented new approaches for planning its inspection activity--based
on analyses of accident, inspection, and other data--that allow it to
better target the greatest safety risks and more effectively use its
inspectors.
National Rail Safety Action Plan Provides Strategy for Addressing
Highest Priority Risks, but Impact of Safety Initiatives Is Not Yet
Clear:
FRA's May 2005 National Rail Safety Action Plan provides an overarching
framework for the agency's efforts to target its oversight at the
highest priority risks. The agency developed the plan in response to a
leveling off of the train accident rate in recent years and the
occurrence of serious train accidents in 2004 and early 2005. The plan
outlines a number of initiatives aimed at reducing the main types of
train accidents, those caused by human factors and track
defects.[Footnote 13] These efforts include some innovative approaches
for the railroad industry, such as a pilot project for reporting close
calls, that are designed to prevent accidents by addressing safety
problems that may cause them.[Footnote 14] Other efforts include new
regulations, several research endeavors, and new track inspection
vehicles. We have not reviewed these individual initiatives in depth,
but believe that the plan provides a reasonable strategy for guiding
and prioritizing FRA's efforts to reduce the rates of accidents
attributable to human factors and track defects.
Some of the efforts outlined in the action plan are underway, and some
are planned for the near future. FRA issued a progress report to the
Secretary of Transportation on the action plan in June 2006 and intends
to continue to report on the plan's implementation. Since issuing the
plan, the agency has pursued additional initiatives to target risks
posed by human factors and track defects, including issuing new track
regulations in response to a congressional mandate and encouraging a
new braking technology. (See table 2.) The combined initiatives hold
promise for reducing the risks associated with human factors and track
defects. However, these efforts are in varying stages of development or
implementation and their overall impact on safety will probably not be
apparent for a number of years. Some individual initiatives, such as
the close call reporting project, may start showing results in the next
year or two.
Table 2: Key FRA Initiatives Aimed at Addressing Main Causes of Train
Accidents:
Cause of train accidents: Human factors;
Initiative: Rail Safety Action Plan initiatives: Regulations on
employee compliance with railroad operating rules;
FRA action and time frame: Issued proposed regulation in October 2006.
Plans to issue final regulation by the end of 2007.
Cause of train accidents: Human factors;
Initiative: Rail Safety Action Plan initiatives: Pilot project to
establish voluntary reporting system to learn from close call
incidents;
FRA action and time frame: Plans to initiate this 5-year project in
January 2007 at one Class I railroad site. FRA is seeking the
participation of other railroads.
Cause of train accidents: Human factors;
Initiative: Rail Safety Action Plan initiatives: Research on worker
fatigue to develop a model that could be used to improve crew
scheduling;
FRA action and time frame: Discussed results of the research with key
stakeholders and released a report on the results in November 2006.
Cause of train accidents: Human factors;
Initiative: Other initiatives: Pilot project to establish voluntary
risk management programs at railroad worksites;
FRA action and time frame: Is considering establishing a pilot project
in fiscal year 2008.
Cause of train accidents: Human factors;
Initiative: Other initiatives: Encouraging new braking technology that
can prevent or reduce human error;
FRA action and time frame: Released a study on new brake system
technology in August 2006 and plans to issue proposed regulations in
May 2007 to facilitate its use.
Cause of train accidents: Track defects;
Initiative: Rail Safety Action Plan initiatives: New track inspection
vehicles;
FRA action and time frame: Plans to deploy two new vehicles in early
2007.
Cause of train accidents: Track defects;
Initiative: Rail Safety Action Plan initiatives: Research and
development on new inspection technologies;
FRA action and time frame: Demonstrated a prototype system in October
2005. Enhanced the system in 2006 and is planning further enhancements
in 2007.
Cause of train accidents: Track defects;
Initiative: Other initiatives: Additional regulations on continuous
welded rail track;
FRA action and time frame: Issued a final rule on rail joint inspection
in October 2006. Plans to develop additional regulations for improving
management of this type of track, but has not yet developed time frames
for this effort.
Source: GAO analysis of FRA data.
[End of table]
The National Rail Safety Action Plan also outlines the agency's
development of a new approach for planning its inspections, based on
greater use of its accident and inspection data. Since issuing the
plan, FRA has made other efforts to improve its approach for planning
its inspections.[Footnote 15] Starting in fiscal year 2006, FRA's new
inspection planning approach has allowed the agency to better target
its inspections on the basis of risk and to better coordinate
inspection planning among its headquarters and regional offices.
FRA Is Making a Number of Efforts to Reduce Accidents Caused by Human
Factors:
Human factor accidents result from unsafe acts of individuals, such as
employee errors, and can occur for a number of reasons, such as
employee fatigue or inadequate supervision, training, or
staffing.[Footnote 16] FRA has recently issued proposed regulations
aimed at reducing the most common causes of such human factor train
accidents: improper positioning of track switches or derails,[Footnote
17] shoving rail cars without properly monitoring for safe conditions
or controlling the movement, and leaving rail cars in a position that
obstructs adjacent track. Procedures for employees to follow to avoid
these types of accidents are contained in railroads' operating
rules.[Footnote 18] Currently, FRA regulations contain general
requirements that railroads train employees on their operating rules
and periodically test their compliance with these rules, but do not
specifically require that employees follow the rules that can prevent
these types of accidents.[Footnote 19] As a result, according to FRA
officials, the agency has had a limited ability to cite noncompliance
and take enforcement actions in this area. The proposed regulations
mirror established railroad operating rules that require employees to
follow procedures, such as procedures related to the positioning of
track switches, that if followed, could prevent these types of
accidents. In addition, they include further requirements for railroads
to train employees on these rules and monitor their compliance with
these rules. According to FRA, these new requirements and its ability
to enforce them will make railroad employees more accountable for
following operating rules and railroad management more accountable for
ensuring that employees do so.
FRA is also sponsoring a 5-year Confidential Close Call Reporting
System pilot project, through which employees of participating
railroads can provide confidential information on close calls. A
neutral party, the Bureau of Transportation Statistics, will maintain
the close call data and a team of representatives from the
participating railroad, labor organizations, FRA, and the bureau will
review these data to identify safety problems. Railroads will be
expected to correct identified problems in order to prevent accidents.
The purpose of this project is to determine the effectiveness of such a
voluntary reporting system for the railroad industry. FRA has developed
plans to monitor and evaluate the performance of the project over time;
these plans include short-term and long-term performance measures. The
agency anticipates that it will have early indications of how the
program is affecting safety in the next year or two. To date, one Class
I railroad has committed to participate in this project, at one yard on
its system, and, according to FRA, two others have expressed strong
interest. Such systems have contributed to significant reductions in
accidents in some other industries, such as aviation.
FRA and the National Transportation Safety Board (NTSB) have identified
employee fatigue as a significant factor in many train accidents.
Railroad employees often work long hours and have unpredictable and
fluctuating work schedules. Under current law, these employees could
potentially work a maximum of 11 hours and 59 minutes, followed by 8
hours off duty, and then another 11 hours and 59 minutes on duty,
continually.[Footnote 20] In addition, time spent waiting for
transportation at the end of a tour of duty and being transported to a
release point, called limbo time, does not count as either duty or off-
duty time and can be significant. FRA has sponsored a study to develop
a fatigue model that could be used to improve train crew scheduling
practices, has discussed the draft results with railroads and labor
organizations, and released the final report on the study in November
2006. The agency is also taking some other actions to encourage
railroads to improve their management of employee fatigue, such as
providing funding for a new program, in use at a Class I railroad, that
tracks and analyzes crew scheduling to remedy practices that could
contribute to fatigue.
Through a recent investigation of a 2004 train accident in which three
people died, NTSB found that the engineer and conductor were likely
asleep at the controls and recommended that FRA require railroads to
use scientifically based principles when assigning work schedules for
train crew members and to limit crew member limbo time.[Footnote 21] In
recent testimony, the FRA Administrator noted that, several times in
the 1990s, the Department of Transportation proposed legislation to
repeal or reform the hours-of-service law or to require railroads to
develop fatigue management plans, but that these bills encountered
opposition and were not passed. However, since that time, FRA has not
submitted such legislation. The agency has not yet responded to NTSB's
recommendations, but has told us that it intends to tell the board, as
it has in the past, that the agency lacks jurisdiction to issue
regulations addressing hours of service.[Footnote 22]
While we were conducting our work, FRA was considering establishing a
pilot project that would use risk management to help reduce human
factor accidents at selected railroad worksites. Risk management can be
described as a systematic approach for identifying, analyzing, and
controlling risks.[Footnote 23] The agency envisioned that, under such
a project, each worksite would collect and analyze data on precursors
to human factor accidents--such as close call incidents, employee
errors, or organizational characteristics--to better identify and
correct individual and organizational factors that contribute to such
accidents and therefore reduce the risks of such accidents occurring.
The agency proposed that funding for this project be included in its
fiscal year 2008 budget request and this proposal was approved by the
department. In January 2007, as we were finalizing our report, FRA told
us that it had decided to expand the scope of this project to include
efforts to use risk management to reduce all types of accidents, not
only human factor accidents.
FRA has examined possible approaches to use for this project. According
to agency officials, one possible approach is represented by a new
program that a Class I railroad has implemented at two locations on its
system. In this program--which has received funding from FRA--a
committee of employees documents employee behaviors that could lead to
unsafe conditions, without recording names, and provides feedback to
the responsible employees to help them eliminate these behaviors. FRA
has also considered the approach used by the Occupational Safety and
Health Administration's Voluntary Protection Program. This program
recognizes individual worksites with exemplary safety records and
practices, including the identification, analysis, prevention, and
control of workplace hazards that could lead to employee injuries and
illnesses.[Footnote 24]
As envisioned by FRA officials, this project will focus on establishing
risk management programs at three separate railroad worksites and will
include close monitoring and evaluation of these programs to determine
their impact in reducing accidents over a 5-year period. If the pilot
is successful, FRA anticipates establishing a voluntary risk management
program for the railroad industry, which would encourage railroads to
implement this type of approach on a systemwide basis in order to
reduce human factor accidents, as well as other types of accidents.
Finally, FRA has recently issued a study on a new braking technology,
electronically controlled pneumatic brakes, which improves train-
handling and decreases stopping distances by 40 to 60 percent. These
brakes use an electronic line to uniformly command brake applications
and releases throughout the train. FRA has decided that it will develop
new regulations to facilitate the use of this technology over the next
decade. According to FRA officials, improving railroads' braking
systems can have a significant safety benefit by improving the ability
of locomotive engineers to control their trains and, therefore, avoid
or reduce the severity of some types of human factor-caused
accidents.[Footnote 25]
The above initiatives use a variety of approaches, some quite
innovative, for addressing the causes of human factor accidents. These
initiatives, which are in varying stages of development or
implementation, have the potential to eventually reduce these types of
accidents. However, while some may start showing results in the next
year or two, their overall impact will likely not be apparent for a
number of years. Furthermore, all of these initiatives, except for the
proposed regulations on operating rules, depend on voluntary actions by
railroads, and, in some cases, labor as well, for their success. For
example, the impact of FRA's effort to develop a model to address the
problem of worker fatigue depends on the extent to which railroads
eventually use this model to improve train crew scheduling practices.
FRA has worked with railroads and labor on some of these initiatives,
but it is too early to predict their outcomes.
FRA Is Pursuing Several Initiatives to Improve the Detection and
Management of Track Defects:
Railroads operate trains on about 219,000 miles of track across the
United States. This track consists of traditional jointed rail as well
as newer rails that are smooth bands of welded steel, called continuous
welded rail. Derailments can occur when rails are uneven or too wide
apart or when rails or joint bars are cracked or broken. FRA inspects
track conditions through manual inspections conducted on-foot or in on-
track equipment, and with automated track inspection vehicles that
precisely measure track and can identify problems that are difficult to
detect through other types of inspections. The agency operates one
automated track inspection vehicle that it uses in inspecting track and
plans to add two more for this purpose in early 2007.[Footnote 26]
According to FRA, these additional vehicles will allow the agency to
triple the miles of track that it is able to inspect per year, to
nearly 100,000 miles.[Footnote 27]
FRA is also developing an automated inspection system for improving the
detection of cracks in joint bars. Such cracks can lead to a derailment-
causing break but can be difficult to detect through simple visual
inspections. Specifically, FRA has designed and is refining a high-
resolution video inspection system that can be used in on-track
inspection equipment and will improve detection of these
defects.[Footnote 28] According to FRA, the technology is ready for
use, was demonstrated and refined in the field in 2006, and will
undergo further enhancements in 2007. The agency expects that railroads
will make use of the technology and is reviewing how to use it in its
own inspections. According to FRA, one Class I railroad is starting to
make use of this technology and others have shown strong interest in
it.
Finally, in response to a congressional mandate and NTSB
recommendations, FRA has recently finalized regulations that require
track owners to conduct detailed and periodic inspections of rail
joints in continuous welded rail track. Although FRA issued regulations
in 1998 requiring railroads to develop and implement procedures for the
inspection and maintenance of continuous welded rail track, a number of
train accidents occurred since that time in which the failure of a rail
joint on this type of track was a factor.[Footnote 29] FRA officials
told us that the railroads' overall management of the condition of
continuous welded rail track is a major concern for the agency because
about 20 accidents involving problems with this type of track occur per
year and these accidents are usually serious. FRA has estimated that
continuous welded rail track represents between 99,000 and 120,000
miles of the 219,000 miles of track in operation in the United States.
The agency is working with the Railroad Safety Advisory Committee to
develop additional regulations to improve railroads' management of this
type of track.
These initiatives have the potential to reduce accidents caused by
track defects. FRA's deployment of two new track inspection vehicles in
early 2007 will enable the agency to significantly expand its ability
to monitor the condition of the nation's track. The agency's
development of an automated inspection system has the potential to help
prevent derailments, provided that railroads make use of this
technology. Finally, FRA's issuance of new regulations related to
continuous welded rail track and development of further regulations in
this area should eventually improve railroads' management of this type
of track, although time frames for the development of new regulations
are not yet clear.
FRA Has Made Progress in Targeting Its Inspections on the Basis of
Risk:
Like other modal safety administrations within the Department of
Transportation, FRA has few resources for overseeing railroads compared
with the scope of its responsibility. According to agency officials, it
inspects 0.2 percent of railroad operations per year. FRA has developed
a new approach--the National Inspection Plan--for using available data
to target its inspections at the greatest safety risks. The agency
began using the new approach for three of its inspection disciplines
(operating practices, track, and motive power and equipment) in October
2005 and expanded it to the remaining two disciplines (hazardous
materials and signal and train control) by March 2006. The purpose of
the plan is to optimize FRA's ability to reduce the rates of various
types of train accidents as well as releases of hazardous materials.
The plan provides guidance to each regional office on how its
inspectors, who each specialize in one of the five inspection
disciplines, should divide up their work by railroad.
Developing the plan involves two steps. In the first step, FRA
headquarters produces an initial plan for each of the agency's eight
regions. This plan specifies, by inspection discipline, numeric goals
for the level of inspection activity to allocate to each railroad, by
state. These numeric goals are derived from models--based on trend
analyses of accident, inspection, and other data--that predict, by
inspection discipline, locations where train accidents and incidents
are likely to occur within each region and provide the optimal
allocation of inspection resources to prevent accidents.[Footnote 30]
FRA has developed separate models for each inspection discipline based
on how well individual data elements, such as historical information on
inspection results, tend to predict accidents. According to FRA
officials, they expect to refine this new planning process to reflect
lessons learned during the first year of its implementation.
In the second step, the regional administrators are allowed to adjust
the goals for their region on the basis of local knowledge and emerging
issues, such as recent accidents. However, according to FRA officials,
there were only a few such adjustments for fiscal year 2006. Throughout
the year, FRA monitors how the regions are meeting their goals.
Starting in fiscal year 2007, regional administrators will have a
second opportunity to adjust their inspection plans at midyear to
respond to safety issues that emerged during the first 6 months of the
year.
Previously, FRA had a less structured, less consistent, and less data-
driven approach for planning inspections. According to agency
officials, each region prepared its own inspection plan, based on
judgments about appropriate priorities and analysis of available data.
However, the use of data was not consistent from region to region.
Inspectors had greater discretion about where to inspect and based
decisions about priorities on their knowledge of their inspection
territories.
The National Inspection Plan covers federal inspectors, but not state
inspectors. Other than funding training and computer equipment, FRA
does not provide funding for state inspection activities.[Footnote 31]
Therefore, each state makes its own decisions about how to use its
inspectors. FRA officials told us that the agency has not included
states in the National Inspection Plan because it does not have
authority to tell the states what inspections to conduct. The 30 states
that participate in FRA's state program have varying numbers of
inspectors and most conduct inspections in some, but not all, of FRA's
five inspection disciplines. According to FRA, its regional offices
coordinate with the states in their region to avoid duplication of
effort. The regional administrators may make adjustments to their
National Inspection Plan goals based on the work of state inspectors
within their region.
The National Inspection Plan also does not establish priorities across
regions and inspection disciplines, but rather, for given staffing
levels for each discipline within each region, assigns inspection
levels to railroads and states. However, FRA eventually plans to use
its results to help decide how to optimally allocate additional
inspectors, as vacancies occur or new positions are funded. According
to headquarters officials, the National Inspection Plan model played a
role in a decision to allocate additional inspection staff to the
operating practices discipline in the regions.[Footnote 32] However,
officials told us that they will need more time to determine how well
the plan is working before using it to reallocate resources among the
regional offices.
The fiscal year 2006 plan resulted in various reallocations of
inspection activity within FRA's regional offices. These reallocations
have allowed FRA to better target its inspections on the basis of risk.
For example, in the track area, in some cases regions are focusing more
attention on certain railroads that have higher accident rates and
worse track conditions than others. Conversely, in the area of
operating practices, some regional offices have decreased their focus
on certain railroads that have shown good or improving performance in
this area compared with other railroads.
In fiscal year 2006, in addition to implementing the National
Inspection Plan, the agency implemented a new coordinated approach for
planning nonroutine inspection activity, by inspection discipline.
Examples of these types of inspections include in-depth inspections by
a regional office of a railroad's compliance with track standards;
interregional inspections of compliance with certain regulations, such
as those related to bridge safety, of a Class I railroad that operates
in multiple regions; and headquarters-led inspections of Class I
railroads' drug and alcohol testing programs. Some of these planned
inspections are based on analyses of data on accidents by railroad,
accident causes, and inspection results in order to define, beyond the
National Inspection Plan goals, what railroad locations and specific
regulatory requirements warrant increased attention by inspectors.
Others, such as inspections of some required railroad safety programs,
are performed periodically. According to FRA officials, the regional
offices and headquarters previously planned such inspections separately
and made less use of data in their planning. Under this new planning
approach, FRA headquarters and regional offices coordinate in
developing plans for inspections they will conduct, by inspection
discipline. These plans are compiled into an agencywide plan, and then
FRA tracks the completion of these inspections.
FRA's new approaches for planning its inspection activity allow it to
better target the greatest safety risks and coordinate inspection
planning among its eight regional offices and headquarters offices.
Therefore, they allow FRA to make more effective use of its inspectors.
However, it is not yet clear whether these new planning approaches will
lead to a prioritization of inspection levels across regions and
inspection disciplines or improved safety.
FRA Relies Primarily on Direct Inspections to Identify Safety Problems
and Does Not Oversee Railroads' Management of Safety Risks:
In carrying out its safety oversight, FRA identifies safety problems on
railroad systems mainly through routine inspections to determine
whether operations, track, and equipment, such as signals and
locomotives, are in compliance with safety standards. Through this
approach, FRA inspectors identify a range of safety problems at various
sites on railroads' systems, through citing defects and violations. FRA
also identifies some broad-scale compliance problems that affect
multiple sites, mainly through analyses of accident and inspection
data, internal discussions, and some nonroutine inspections.
FRA's inspections focus on compliance with minimum standards within
five separate inspection disciplines and do not attempt to determine
how well railroads are managing safety risks on their systems. APTA,
PHMSA, and Transport Canada have implemented approaches to oversee the
management of safety risks by U.S. commuter railroads, U.S. pipelines,
and Canadian railroads, respectively. These oversight approaches
complement, rather than replace, traditional compliance inspections and
therefore provide additional assurance of safety. However, we are not
recommending that FRA adopt such an oversight approach, since the
agency is currently pursuing various initiatives to reduce train
accident rates. In our view, these initiatives need time to mature to
demonstrate their effects and, subsequently, an informed assessment
would need to be made about whether additional actions are warranted.
FRA's Oversight Identifies a Range of Site-Specific and Broad-Scale
Problems on Railroad Systems:
Overseeing the safety of the railroad industry is a huge task. FRA's
400 inspectors, along with about 160 state inspectors, oversee 686
railroads, with about 235,000 employees, 219,000 miles of track, 24,000
locomotives, 1.6 million cars, 158,000 signals and switches, and
240,000 highway-rail grade crossings.[Footnote 33] As noted previously,
according to FRA officials, the agency's inspectors are able to
directly observe only about 0.2 percent of the railroad industry's
operations per year. FRA carries out this oversight responsibility
primarily through inspections of railroads' compliance with its safety
standards at various locations on railroads' systems and through
cooperation and enforcement aimed at resolving identified problems.
During inspections, which are generally conducted separately within the
five inspection disciplines, inspectors examine railroads' compliance
with a broad range of federal standards. Inspectors discuss identified
compliance problems (called defects) with railroads to achieve
voluntary compliance, and cite violations--recommending that the agency
take enforcement action against a railroad--when they determine that
the problems are serious or when a railroad does not voluntarily
comply. (See app. II for a description of FRA's use of cooperation and
enforcement to resolve safety problems and improve safety.) In
addition, FRA's Railroad System Oversight managers work with Class I
railroads and labor to identify and resolve some safety problems that
are not directly related to compliance with the agency's regulations.
For example, one manager worked with a railroad and labor organization
to improve the railroad's program for communicating with roadway
workers to ensure that they are aware of and implement key safety
procedures.
FRA primarily monitors railroads' compliance through routine
inspections by individual inspectors at specific sites on railroads'
systems.[Footnote 34] As discussed previously, FRA inspects locations
likely to have safety problems, which it identifies using accident and
previous inspection data as well as other information. Inspectors
typically cover a range of standards within their discipline during
these inspections. This inspection approach focuses on direct
observations of specific components of the train, related equipment,
and railroad property--including the track and signal systems--as well
as operating practices to determine whether they meet FRA's standards.
(See figs. 6 and 7.) Inspectors also examine railroads' inspection and
maintenance records. The railroads have their own inspectors who are
responsible for ensuring that railroad equipment, track, and operations
meet federal rail safety standards. For example, FRA requires that
railroads inspect brake systems, signal systems, passenger equipment,
track conditions, and train crews' adherence to operating rules, among
other things. According to FRA officials, the agency's inspectors often
review the railroads' records of inspection to determine whether the
records accurately represent the types of problems FRA inspectors are
finding during their own inspection activities.
Figure 6: FRA Inspector Measuring Track Gauge:
[See PDF for image]
Source: FRA.
[End of figure]
Figure 7: FRA Inspector Inspecting Train Cars:
[See PDF for image]
Source: FRA.
[End of figure]
FRA also conducts more in-depth inspection efforts that generally focus
on railroads' compliance in a particular area, such as their
inspections of employees' adherence to operating rules. These efforts
often involve a team conducting separate inspections at multiple sites,
generally within one of FRA's eight regions.[Footnote 35] FRA focuses
these in-depth inspection efforts on emerging issues, identified
through previous routine inspections or analyses of accident data. FRA
also periodically conducts in-depth inspections of some systemwide
programs that the railroad is required to implement, such as employee
drug and alcohol testing programs and accident and incident reporting
programs. In some cases, FRA may conduct a systemwide in-depth set of
inspections on a railroad to determine its overall compliance within a
single inspection discipline or in several disciplines. For example, in
early 2006, in response to a Class I railroad's high accident rates,
FRA conducted an in-depth set of inspections of the railroad's
compliance with operating practices, track, signal and train control,
motive power and equipment, and hazardous materials regulations across
its system. However, according to an FRA headquarters official, the
agency does not frequently perform systemwide or multidisciplinary
inspections.
In 2005, federal and state inspectors conducted a total of about 63,000
inspections.[Footnote 36] According to FRA, routine inspections
constituted about 75 percent of the inspections of railroads and in-
depth inspections accounted for about 11 percent. The remainder of
these inspections (14 percent) consisted of other types of activities,
such as investigations of accidents and complaints. Inspectors in the
track discipline performed the most inspections, followed by those in
the motive power and equipment, operating practices, hazardous
materials, and signal and train control disciplines.[Footnote 37] This
approach to oversight enables FRA inspectors and managers to identify a
wide range of safety problems. Inspectors identify specific compliance
problems--conditions that do not meet FRA's standards--at sites they
visit by citing defects. Inspectors cite violations for those defects
that they believe warrant enforcement action. They consider a number of
factors in making this decision, including the railroad's history of
compliance at that location and the seriousness of the noncompliance
(such as whether it is likely to cause accidents, injuries, or releases
of hazardous materials). Inspectors in some disciplines cite more
defects and violations than others. (See fig. 8.) Overall, FRA and
state inspectors cited about 293,000 defects and about 9,500 violations
during the 63,000 inspections conducted in 2005.
Figure 8: Inspections Conducted and Defects and Violations Cited, by
Inspection Discipline, in 2005:
[See PDF for image]
Source: GAO analysis of FRA data.
Note: These figures include inspections carried out by both federal and
state inspectors. Inspectors are instructed to cite defects for most
instances of noncompliance found, but have discretion in determining
which instances to cite as violations warranting enforcement action.
[End of figure]
The motive power and equipment discipline cites almost half of all
defects and over a third of all violations. FRA officials told us that
the standards in this inspection discipline are the most prescriptive,
making defects and violations easier to find. However, these types of
defects cause a much smaller proportion of accidents than human factors
and track defects.[Footnote 38] (See fig. 4.) The most frequently cited
violations include those for noncompliance with standards regarding
locomotives and freight cars, track conditions, recordkeeping on the
inspection and repair of equipment and track, and the condition of
hazardous materials tank cars.
While individual defects and violations are generally for compliance
problems identified at specific locations on railroads' systems, FRA
also identifies broad-scale compliance problems, by inspection
discipline, that affect multiple locations on a railroads' system. It
does so mainly through analyses of accident data and data on defects
and violations found during inspections, communications among managers
at headquarters and in its eight regional offices on the results of
analyses and inspections, and further inspections to obtain more
information about identified problems. Agency officials told us that
they hold frequent internal discussions about emerging issues to
determine where problems are occurring and plan actions that the agency
should take to address them. The agency's Railroad System Oversight
managers support this effort by analyzing systemwide accident and
inspection data, by inspection discipline, for the Class I railroads to
identify trends and emerging issues. FRA may plan and conduct in-depth
inspections to determine the scope of such issues. For example, if the
rate of human factor accidents has increased at various locations on a
railroad's system, FRA may conduct inspections of operating practices
at these locations.
Examples of broad-scale problems FRA has identified at railroads
include weak implementation within a particular state of a program for
monitoring employees' adherence to operating rules, poor inspections by
a railroad of its track in a particular region, systemic problems in
reporting accidents and incidents, and defective equipment across a
railroad's system. In some cases, FRA inspectors identify some higher-
level management issues, such as a lack of supervision or inadequate
training of railroad personnel, which could have led to the compliance
problems. According to FRA officials, they discuss broad-scale
compliance problems with railroad officials to try to get these
problems resolved. For example, after an in-depth inspection,
inspectors meet with railroad managers to discuss overall problems
found and, according to headquarters officials, usually provide a
written summary of those problems. Efforts to cooperate with the
railroad to resolve broad-scale problems may be combined with
enforcement actions, usually civil penalties, for specific violations
identified at individual sites. According to FRA officials, the agency
always conducts follow-up on serious problems it has identified to
ensure that they are resolved.[Footnote 39]
While FRA does track and maintain data on various types of train
accidents and incidents as well as defects and violations cited by
inspectors and enforcement actions taken, the agency does not centrally
track the broad-scale compliance problems it has identified.[Footnote
40] These problems are described in some agency documents, such as
inspectors' summary reports on findings of in-depth inspection efforts;
various reports prepared by the Railroad System Oversight managers on
the Class I railroads;[Footnote 41] and the agency's overall plan, by
region and inspection discipline, for its nonroutine inspection
activity. As explained in the next section, this lack of centralized
tracking can impede the ability of the agency to measure the
effectiveness of its efforts to resolve identified broad-scale
problems.
FRA's five Railroad System Oversight managers also identify some broad
safety problems at Class I railroads that are not related to
compliance. They identify these problems mainly through contacts with
labor and railroad officials and FRA regional officials and try to
address them through cooperation with the railroad. For example, these
managers have worked with railroads in addressing labor's concerns
about practices for transporting train crews at the end of their shifts
that may worsen fatigue and programs for training employees on the
railroads' operating rules. In some cases, these problems were first
identified under the Safety Assurance and Compliance Program.
Several Other Organizations Have Implemented Comprehensive Approaches
for Overseeing the Management of Safety Risks in Transportation
Industries:
FRA officials have noted that their approach of directly inspecting
safety conditions and targeting locations that are most likely to have
compliance problems provides a safety net and holds railroad management
accountable. However, because the number of FRA and state inspectors is
small relative to the size of railroad operations, FRA inspections can
cover only a very small proportion of railroad operations (0.2
percent). Also, FRA targets inspections at locations on railroads'
systems where accidents have occurred, among other factors, rather than
overseeing whether railroads systematically identify and address safety
risks that could lead to accidents.
Rail transportation poses a variety of potential safety hazards,
including collision or derailment; injury to workers, passengers, or
nearby residents; and damage to property or the environment. Risk
management is a systematic approach for dealing with the risks posed by
such safety hazards and has been used in the private and public sectors
for decades. It can be described as a continuous process of managing--
through the systematic identification, analysis, and control of risks
associated with hazards (or threats)--the likelihood of their
occurrence and their negative impact.[Footnote 42] A framework for risk
management based on industry best practices and other criteria that we
have developed divides risk management into five major phases: (1)
setting strategic goals and objectives, and determining constraints;
(2) assessing risks; (3) evaluating alternatives for addressing these
risks; (4) selecting the appropriate alternatives; and (5) implementing
the alternatives and monitoring the progress made and results
achieved.[Footnote 43] Risk management can help to improve systemwide
safety by systematically identifying and assessing risks associated
with various safety hazards and prioritizing them so that resources may
be allocated to address the highest risks first. It also can help in
ensuring that the most appropriate alternatives to prevent or mitigate
the effects of hazards are designed and implemented.
Other transportation oversight organizations have developed and
implemented approaches for overseeing industries' overall management of
safety risks. In particular, during the last 10 years, APTA, PHMSA, and
Transport Canada have developed and implemented such oversight
approaches for U.S. commuter railroads, U.S. pipelines, and Canadian
railroads, respectively. These approaches complement, rather than
replace, traditional compliance inspections. APTA established a U.S.
commuter railroad oversight program in 1996, in partnership with FRA
and the commuter rail industry, that supplements FRA's inspections of
these railroads.[Footnote 44] Under this program, APTA provides
guidelines to these railroads on managing the safety of their systems-
-including safety risks--and audits their plans for and implementation
of this management approach. Beginning in 2000, PHMSA issued a series
of requirements for pipeline operators to develop "integrity
management" programs to manage risk in areas--such as those that are
densely populated--where leaks or ruptures could have the greatest
impact on public safety.[Footnote 45] The agency's integrity management
regulations supplement its minimum safety regulations, and it inspects
operators' compliance with both types of standards. In Canada, the
department responsible for overseeing railroad safety, Transport
Canada, in 2001 began requiring that railroads establish safety
management systems that include risk management.[Footnote 46] Transport
Canada assesses these systems as well as railroads' compliance with its
traditional safety standards.[Footnote 47] (For further information on
GAO's risk management framework and these oversight approaches, see
app. III.)
These oversight approaches are intended to provide additional assurance
of safety beyond that provided by inspections of compliance with
minimum safety standards. They supplement uniform, minimum standards by
encouraging or requiring companies to identify and address their unique
safety risks. APTA, PHMSA, and Transport Canada have emphasized that
risk management provides a higher standard of performance than
traditional safety regulation based on compliance alone. According to
APTA officials, their approach helps companies to prioritize their
actions for addressing risk and therefore optimize safety within
constraints of their resources. According to PHMSA officials, pipeline
companies' compliance with the agency's traditional regulations ensures
minimum safety performance, but its integrity management approach has
improved the ability of these companies to systematically address the
full range of safety threats to their pipelines. According to Transport
Canada officials, by encouraging systemwide improvements in companies'
safety performance in order to address systemic causes of specific
problems, its new approach helps the agency to leverage its resources.
Transport Canada has emphasized that risk management ensures that risks
are being adequately addressed and should point railroads to areas
where they could undertake initiatives beyond their current practices
that could improve their overall safety performance. Transport Canada
officials also told us that a primary objective of their new approach
is for railroads to assume more responsibility for the safety of their
operations. Similarly, APTA officials told us that their oversight
approach is proactive because it encourages companies to identify and
address potential hazards before accidents occur.
We have reviewed PHMSA's gas transmission pipeline integrity management
oversight approach and have recently concluded that it enhances public
safety.[Footnote 48] We also found that representatives from the
pipeline industry, safety advocacy groups, and state agencies generally
agree that this approach improves public safety. Operators told us that
the primary benefit of the program is the comprehensive knowledge they
acquire about the condition of their pipelines. APTA and Transport
Canada officials have told us that their oversight approaches have not
been formally evaluated to determine their effectiveness. However,
according to FRA officials, APTA's system safety oversight approach has
strengthened safety program management in the commuter rail sector.
Finally, Transport Canada is expanding its safety management system
approach to its oversight of civil aviation.
While FRA does not oversee railroads' overall approach for managing
safety risks on their systems, it has taken some steps in a limited
number of areas to oversee and encourage risk management in the
railroad industry. For example, the agency has several regulations in
place that require railroads to use a risk-based approach for managing
safety in specific areas: the operation of high-speed passenger trains,
the fire safety of new passenger cars and locomotives, and the adoption
of new processor-based signal and train control technologies. In
addition, PHMSA, in consultation with FRA and the Transportation
Security Administration, has recently proposed a regulation that could
lead to greater FRA oversight of railroads' management of hazardous
materials risks.[Footnote 49] FRA has also issued guidance for
passenger railroads on assessing collision hazards and risks and
developing strategies for addressing them.[Footnote 50] In addition,
FRA is currently working with APTA and some commuter railroads to
improve these railroads' abilities to conduct collision hazard
analyses. Finally, as discussed earlier, FRA is considering
establishing a pilot project to examine how a risk management approach
could be used in the railroad industry, on a voluntary basis, to reduce
human factor accidents as well as other types of accidents.
Although FRA is taking some steps to encourage increased use of risk
management in the railroad industry, oversight of railroads' overall
approach for managing safety risks on their systems, in addition to
FRA's existing discipline-specific compliance-based oversight, has the
potential to provide additional assurance of safety. Such an approach
could help to ensure that railroads systematically identify and address
the full range of risks on their systems and could also encourage
railroads to take on more responsibility for safety. According to
agency officials, FRA is concerned that railroads too often wait for
inspectors to show up before addressing problem areas, while FRA would
prefer that they find and fix problems on their own. However,
developing and implementing such a new oversight approach would be a
major undertaking for the agency and would also require the support and
participation of the railroad industry.
While we believe that adopting a comprehensive approach for overseeing
railroads' management of safety risks, similar to the approaches
discussed in this section, can lead to improved safety, we are not
making a recommendation aimed at encouraging FRA to adopt such an
oversight approach. As discussed in the previous section, FRA is
pursuing several initiatives aimed at reducing train accident rates. In
our view, these initiatives need time to mature to demonstrate their
effects and, at the appropriate time, the department may wish to
conduct an informed assessment to determine whether additional actions
are warranted.
FRA Measures Its Progress in Achieving a Variety of Safety Goals, but
Has Limited Information on the Direct Results of Its Oversight:
FRA has a broad range of goals and measures that it uses to provide
direction to and track the performance of its safety oversight
activities. However, its ability to make informed decisions about its
inspection and enforcement programs is limited because it lacks
measures of the intermediate outcomes, or direct results, of these
programs that would show how they are contributing toward the end
outcomes, or ultimate safety improvements, that the agency seeks to
achieve. Furthermore, while FRA has made some changes in its oversight
approach in response to external and internal evaluations, it has not
evaluated the effectiveness of its enforcement approach. Evaluations
can provide a broader range of information on program performance and
how to improve it than performance measures alone. Both performance
measures and evaluations can provide valuable information on program
results that helps hold agencies accountable for their programs'
performance.
FRA Has Established a Range of Safety Goals and Uses Cooperation and
Enforcement to Achieve These Goals:
To its credit, FRA has adopted a range of useful safety performance
goals.[Footnote 51] These safety goals are useful because they help the
agency target its oversight efforts to help achieve the department's
goals of reducing (1) the rate of rail-related accidents and incidents
and (2) the number of serious hazardous materials releases. For fiscal
year 2007, FRA established six new agencywide safety goals that are
aligned with its five inspection disciplines and its grade crossing
efforts. These goals are to reduce the rates of (1) accidents caused by
human factors; (2) accidents caused by track defects; (3) accidents
caused by equipment failure; (4) accidents attributable to other
causes, including signal defects; (5) hazardous materials releases; and
(6) grade-crossing incidents. These departmental and agency goals
represent the key end outcomes, or ultimate results, FRA seeks to
achieve through its oversight efforts. The agency has also recently
established regional office goals that are generally aligned with the
new agencywide goals. These regional office goals help FRA to link the
oversight activities of its eight regional offices with its overall
goals.
FRA officials told us that their inspection and enforcement programs
contribute to meeting these safety goals, or end outcomes, by resulting
in the correction of safety problems and compliance.[Footnote 52] These
desired direct results can be called the intermediate outcomes of the
inspection and enforcement programs, although FRA has not identified
them as such. FRA officials told us that they use a combination of
cooperation with railroads and enforcement actions to achieve the
correction of safety problems and compliance. The linkages between such
program outputs and desired intermediate and end outcomes can be
demonstrated in a "logic model" that helps to show how program
activities contribute to the ultimate results the agency seeks to
achieve.[Footnote 53] (See fig. 9.)
Figure 9: How FRA's Inspection and Enforcement Programs Contribute to
Rail Safety:
[See PDF for image]
Source: GAO analysis of FRA information.
Note: The program outputs and intermediate outcomes identified in this
figure are examples of the outputs and intended direct results of FRA's
inspection and enforcement and resulted from discussions with FRA
officials. FRA has not identified these as outputs or intermediate
outcomes. In addition to the agency's inspection and enforcement
efforts, its Railroad System Oversight managers work cooperatively with
the Class I railroads to achieve safety improvements not related to
compliance.
[End of figure]
FRA uses cooperation with railroads and enforcement actions in various
ways to resolve safety problems and achieve compliance. As explained
previously, problems identified in inspections can be site-specific
compliance problems or broader problems affecting multiple sites.
Inspectors try to resolve site-specific compliance problems found
during routine inspections by discussing defects with railroad
officials in order to achieve voluntary compliance. The agency's policy
of focused enforcement requires that inspectors cite violations and
recommend enforcement actions, most frequently civil penalties, for
those compliance problems that pose the greatest safety hazards.
Enforcement actions can require railroads to correct identified
compliance problems as well as deter future noncompliance. After in-
depth inspection efforts at multiple sites, inspectors meet with
railroad managers to discuss overall findings of safety problems that
need to be corrected to achieve compliance. FRA sometimes encourages or
requires railroads to make broad-scale improvements, such as in the
training of railroads' track inspectors, which could help a railroad to
comply with the agency's standards. (See app. II for more information
on how FRA uses cooperation and enforcement to improve safety.)
Performance Measures Support FRA's Oversight, but Information on Direct
Results Is Limited:
Consistent with the Government Performance and Results Act of 1993,
which calls on federal agencies to develop performance measures to help
determine the extent to which intended outcomes are achieved, FRA has
developed a range of performance measures that it uses to track the
progress of--and provide direction to--its safety oversight
programs.[Footnote 54] (See table 3.) A number of these measures
provide useful information about the extent to which various desired
end outcomes, or ultimate results, are being achieved. In particular,
FRA has developed a number of measures, based on agency and regional
goals, that capture important components of its progress in achieving
the department's overall safety goals. Since these new measures are
linked to inspection and enforcement activities of its inspection
disciplines and regional offices, they can provide some useful
information on progress in achieving the desired end outcomes. For
example, the agency expects that inspection and enforcement efforts in
the operating practices discipline will reduce accidents caused by
human factors, and it tracks the extent to which these accidents are
reduced, both at the national and the regional level.
Table 3: FRA's Safety Performance Measures:
Type of measure: End outcomes: Departmental safety goals;
Description: Rate of rail- related accidents and incidents[A] and
number of serious hazardous materials releases.
Type of measure: End outcomes: Agency safety goals;
Description: Rates of train accidents caused by human factors, track
defects, equipment defects, or other (signal and miscellaneous) causes;
rate of nonaccident rail- related hazardous materials releases; and
rate of highway-rail grade crossing incidents.
Type of measure: End outcomes: Regional office safety goals;
Description: By region, numbers of train accidents caused by human
factors, track, equipment, and other causes and numbers of highway-rail
grade crossing incidents.
Type of measure: End outcomes: Class I railroad safety performance
trends;
Description: Trends in rates of accidents of various types for each
Class I railroad.
Type of measure: Program outputs and management: Agency efficiency
goal;
Description: Ratio of safety budget expenditures on safety-related
activities, such as inspections, versus administrative activities.
Type of measure: Program outputs and management: Management of
inspection and enforcement activities;
Description:
* Various measures used in targeting inspections and determining
enforcement actions, including trends in various types of accidents and
employee injuries and cited defects and violations, by inspection
discipline, region, state, and railroad;
* Inspections conducted and costs by region and inspection discipline;
* Extent to which regions are meeting planned targets for inspections;
* Timeliness of reports received from railroads on actions taken to
remedy violations[B];
* Measures related to enforcement, including civil penalties assessed
and collected and processing times.
Source: GAO analysis of FRA information.
[A] Includes train accidents as well as grade-crossing, trespassing,
and other accidents.
[B] For those violations requiring corrective action, railroads are
required, within 30 days after the end of the month in which the
violation occurred, to notify FRA of the actions they have taken.
[End of table]
The agency has adjusted its oversight approach in response to trends in
end outcome measures. For example, it developed the National Rail
Safety Action Plan in response to a flat trend in the overall train
accident rate and an increasing rate of accidents caused by human
factors. In addition, FRA has developed measures to track the
performance of Class I railroads, and it reviews these measures
quarterly to assist in making decisions about oversight of these
railroads.
FRA also uses various measures of program outputs, such as numbers of
inspections and enforcement actions, as well as some other types of
measures to manage its oversight efforts. While the agency does not
track its cooperative efforts to achieve compliance, it does track
inspection and enforcement activities. In fiscal year 2007, the agency
will start using an efficiency measure to track its progress in using
its resources on safety-related activities, such as inspections, rather
than on administrative activities. FRA headquarters and inspection
staff use data on defects and violations cited in inspections, together
with data on accidents and incidents, in planning inspection activities
and making enforcement decisions. Finally, FRA tracks whether railroads
report on actions taken to correct violations within the required time.
While FRA has developed a range of measures of end outcomes and program
outputs, it lacks measures of the desired intermediate outcomes, or
direct results, of its inspection and enforcement efforts--that is, the
correction of identified safety problems and compliance. We have found
that it is a useful practice for agencies to establish measures of
intermediate outcomes to help show programs' contributions to desired
end outcomes.[Footnote 55] According to FRA officials, inspectors
review reports on corrective actions provided by railroads and may ask
a railroad to resubmit a report if they believe that it does not
adequately address the violation.[Footnote 56] FRA officials also told
us that inspectors always follow up on serious problems identified--
both site-specific and broader scale problems--to ensure that they are
corrected, and may cite additional violations if they find continuing
problems.[Footnote 57] However, the agency does not measure the extent
to which identified safety problems have been corrected. Without such a
measure, FRA cannot determine the extent to which its inspection and
enforcement efforts are achieving the desired direct results.
Measuring whether safety problems have been corrected is particularly
important when serious compliance problems are broad-scale, affecting
multiple sites, whether the problems are local, regional, or
systemwide. These problems are sometimes identified in reports of in-
depth inspections. For example, one set of track inspections of a Class
I railroad at various sites within a region in early 2006 led to
overall findings that these locations had deteriorating track
conditions, that no repair work was scheduled, and that the railroad's
track inspections were not adequate.[Footnote 58] According to FRA
officials, headquarters managers and managers of the agency's eight
regional offices frequently discuss serious safety problems, indicated
by the results of field inspections and data analyses, to determine the
scope of the problems and decide on actions the agency should take to
ensure that railroads resolve them. However, while FRA tracks a variety
of safety related data, it does not centrally track these broad-scale
compliance problems or their status and therefore lacks overall
information on the effectiveness of its efforts to ensure that they are
resolved.[Footnote 59]
FRA also lacks overall measures of railroads' compliance. FRA officials
told us that, while defect rates (the ratio of defects found per units
inspected) measure noncompliance found by inspectors, they cannot be
used to produce statistically valid measures of railroads' overall
level of compliance because inspections are focused on problem areas
and FRA is not able to conduct enough inspections of railroads to
ensure that it is getting a good measure of compliance.[Footnote 60]
Officials have emphasized that the agency relies on inspectors' day-to-
day oversight of and interaction with railroads to track compliance.
Also, as noted previously, FRA officials, both at the headquarters and
regional levels, analyze defect data in each inspection discipline to
identify emerging issues and plan inspection activity. Finally,
officials noted that the agency is planning to use its automated track
inspection vehicles to survey most of the national track system and to
monitor improvements in the condition of track over time.
We recognize that developing measures of intermediate outcomes would be
difficult and that it is challenging for regulatory agencies to develop
such measures.[Footnote 61] Nevertheless, some other regulatory
agencies in the Department of Transportation have developed such
measures. For example, the Federal Motor Carrier Safety Administration
measures the percentage of truck companies that improve their
performance in a follow-up inspection and PHMSA measures the extent of
improvement in pipeline operators' integrity management programs, as
indicated by successive inspections of operators' programs. FRA
officials have told us that the fact that the agency has not integrated
its existing safety-related databases has impeded its ability to
develop measures of intermediate outcomes. The agency has an initiative
underway to better integrate these databases, including its database on
accidents and incidents and its inspection and enforcement databases,
in order to better manage its information resources.[Footnote 62]
Performance measures should provide agency managers with information
that helps them make decisions that improve program performance,
including decisions to adjust policies and priorities. As noted, FRA
has used its existing performance measures to make decisions about its
oversight approach in a variety of ways. However, not having measures
of the intermediate outcomes of its inspection and enforcement
approaches limits FRA's ability to make informed decisions about these
approaches and adjust them to improve performance. Intermediate outcome
measures can provide more timely information on program performance
than end outcome measures, because it may take longer for program
efforts to affect end outcomes.
Measures of program results can also help hold agencies accountable for
the performance of their programs. Congress needs information on
program results to support its oversight of agencies and their budgets.
FRA's new discipline-specific and region-specific outcome measures do
help ensure accountability for results. However, without measures of
intermediate outcomes, the extent to which FRA's inspection and
enforcement programs are achieving direct results and contributing to
desired end outcomes is not clear. FRA officials have noted that they
cannot attribute any drops in accident rates solely to FRA's efforts
because other factors, such as railroads' investments in their systems,
also play an important role.
FRA can also use measures of intermediate outcomes to increase
railroads' accountability for correcting safety problems. In spring
2006, the agency instituted annual meetings with the heads of the Class
I railroads to discuss their overall safety performance, using trends
in various accident rates. These meetings are a good step forward for
the agency because they represent an opportunity for FRA to put
pressure on top railroad executives to adequately address major
problems the agency has identified. However, without measures of the
extent to which individual railroads have addressed such problems, FRA
cannot take full advantage of this opportunity. In addition, without
central tracking of these problems and their status, FRA's ability to
identify continuing or recurring problems as well as interrelated
problems and make appropriate enforcement decisions may be impaired,
especially since much of this work is performed in eight separate FRA
regional offices and in five separate inspection disciplines.[Footnote
63] According to FRA, annual meetings with the major railroads to
negotiate civil penalties focus on individual violations but also
address systemic issues that have been identified through analysis of
individual violations. However, regional officials told us that these
meetings do not generally deal with systemic issues. Readily available
information on the status of broader problems would help put a
railroad's individual violations into perspective and could help ensure
that FRA negotiates appropriate final amounts with railroads.
FRA Has Made Changes in Response to Evaluations but Has Not Evaluated
Its Enforcement Approach:
Besides requiring performance measurement, the Government Performance
and Results Act of 1993 calls for agencies to evaluate the
effectiveness of their programs in achieving intended outcomes. We have
found that, since it can be challenging for regulatory agencies to
measure the direct results of their programs, program evaluations are
particularly helpful in determining these results.[Footnote 64] Program
evaluations are objective, systematic studies that answer questions
about program performance and results. By examining a broader range of
information than is feasible to monitor on an ongoing basis through
performance measures, evaluation studies can explore the benefits of a
program as well as ways to improve program performance. They can also
be used to develop or improve agencies' measures of program performance
and help ensure agencies' accountability for program results.[Footnote
65]
FRA's safety oversight activities have recently undergone several
external evaluations by the department's Inspector General, as well as
an internal review, and FRA has made some changes as a result. For
example, on the basis of several reviews since 1998, the department's
Inspector General in 2004 recommended that FRA develop a plan to make
meaningful use of available data to focus its inspection and
enforcement activity.[Footnote 66] FRA developed its National
Inspection Plan in response. Also, in 2004, FRA established a committee
to conduct an internal review of its Safety Assurance and Compliance
Program. This committee solicited the views of various FRA managers on
the strengths and weaknesses of the program. Based on its findings, FRA
terminated this program and replaced it with its Railroad System
Oversight program.
In addition, the Office of Management and Budget assessed FRA's overall
safety program in 2003.[Footnote 67] Although the office found this
overall program to be moderately effective, it also found that FRA had
not arranged for independent evaluations of its design and
effectiveness. In response, FRA arranged for a review of its Railroad
Safety Board process and has stated that it will continue to have
regular independent reviews of various aspects of its safety
program.[Footnote 68] The agency is planning to have an independent
evaluation of its Railroad System Oversight program conducted in the
third quarter of fiscal year 2007. FRA also made some other
improvements in response to recommendations of the Office of Management
and Budget assessment, including developing its new efficiency measure
and procuring new vehicles for conducting track inspections.
Although FRA has modified various aspects of its safety oversight in
response to evaluations, it has not evaluated the extent to which its
enforcement is achieving desired results. In addition to providing
information on program performance and how it could be improved, an
evaluation of FRA's enforcement approach could help to identify data
needed to develop useful performance measures. For example, the Federal
Motor Carrier Safety Administration examined the rate of violations by
trucking companies before and after implementing a policy of assessing
maximum penalties for such violations and, based on initial analyses,
has improved its data system to be better able to analyze this trend.
Under FRA's focused enforcement policy, developed in the mid-1990s,
inspectors cite a small percentage of identified defects (about 3
percent in 2005) as violations that they recommend for enforcement
action, generally civil penalties. While this policy relies, to a great
extent, on cooperation with railroads to achieve compliance and is
intended to focus FRA's enforcement efforts on those instances of
noncompliance that pose the greatest safety hazards, it is not clear
whether the number of civil penalties issued, or their amounts, are
having the desired effect of improving compliance. FRA officials have
told us that they have not evaluated the effectiveness of civil
penalties in ensuring compliance, noting that this would be difficult
because penalty payments usually occur after the agency's yearly
settlement process. However, without an evaluation of its enforcement
program, FRA is missing an opportunity to obtain valuable information
on the performance of this program and on any need for adjustments to
improve this performance.
Conclusions:
The various initiatives that FRA has begun in the past year and a half
to better target its oversight--by addressing the main causes of train
accidents and better focusing inspections on problem areas--hold
promise for bringing down the train accident rate, reducing injuries,
and saving lives. Some initiatives, such as reporting of close call
incidents, encourage the railroad industry to address safety problems
before they result in accidents. However, the success of many of these
initiatives will depend on voluntary actions by the railroads and their
overall safety impact will likely not be apparent for a number of
years. While FRA is pursuing these initiatives, it has not changed its
approach for conducting inspections, which relies primarily on direct
observations of operations, equipment, and track. An additional
approach that has provided additional assurance of safety in the U.S.
commuter railroad, U.S. pipeline, and Canadian railroad industries is
oversight of companies' overall management of safety risks. Although we
believe that a similar approach could help improve rail safety, we are
not recommending that FRA adopt such an approach because its current
initiatives to bring down the train accident rate need time to
demonstrate their effects.
Without measures of the direct results of its inspection and
enforcement programs, FRA cannot demonstrate how these programs are
contributing to rail safety and lacks key information that could help
it improve performance. This information could also help FRA hold
railroads accountable for addressing safety problems it identifies.
While these measures are not always easy to develop, at least one other
modal administration within the department has done so at our
recommendation. Coupled with better measures of FRA's direct results is
the need to assess the effectiveness of its enforcement program,
especially its use of civil penalties, to understand the degree to
which they contribute to improved safety outcomes and to determine
whether it should adjust its approach to improve performance.
Recommendations for Executive Action:
To enhance FRA's ability to determine the extent to which its
inspection and enforcement programs are contributing to rail safety and
whether changes in these programs are needed, we recommend that the
Secretary of Transportation direct the Administrator of FRA to take the
following two actions:
* develop and implement measures of the direct results of its
inspection and enforcement programs; and:
* evaluate the agency's enforcement program to provide further
information on its results, the need for additional data to measure and
assess these results, and the need for any changes in this program to
improve performance.
Agency Comments:
We provided a draft of this report to the Department of Transportation
for its review and comment. The department did not offer overall
comments on the draft report or its recommendations. It did offer
several technical comments, which we incorporated where appropriate.
We are sending copies of this report to congressional committees and
subcommittees with responsibility for transportation safety issues; the
Secretary of Transportation; the Administrator, Federal Railroad
Administration; and the Director, Office of Management and Budget. We
will also make copies available to others upon request. This report
will be available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov].
If you have any questions about this report, please contact me at (202)
512-2834 or siggerudk@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. Staff who made key contributions to this report
are listed in appendix IV.
Signed by:
Katherine A. Siggerud:
Director, Physical Infrastructure Issues:
[End of section]
Appendix I: Scope and Methodology:
To determine how the Federal Railroad Administration (FRA) focuses its
efforts on the highest priority risks related to train accidents in
planning its safety oversight, we reviewed FRA's National Rail Safety
Action Plan, plans for developing new regulations, documents related to
its initiatives for reducing human factor and track-caused accidents,
and inspection planning documents. We also discussed the agency's
inspection planning approach and key initiatives with headquarters and
regional officials responsible for these areas. In addition, we
obtained information on FRA's initiatives through attending
congressional hearings on FRA's oversight and meetings of the Railroad
Safety Advisory Committee.
To determine how FRA identifies safety problems on railroad systems in
carrying out its oversight, we determined how FRA uses its inspections,
the Railroad System Oversight program, and other oversight activities
to oversee safety and identify problems. In order to do this, we
reviewed FRA's regulations, policies, procedures, and guidance for
conducting inspections and identifying safety problems as well as
reports on inspection results. We also reviewed the agency's statutory
authority under the Federal Railroad Safety Act and reviewed Railroad
Safety Oversight program documents. We discussed FRA's oversight
activities with FRA headquarters managers and inspection discipline
specialists and Railroad Safety Oversight managers to gain a greater
understanding of how FRA identifies safety problems on railroad
systems. We also contacted three (Chicago, Forth Worth, and Atlanta) of
the eight FRA regional offices reporting the highest numbers of
accidents in their jurisdictions during 2005. We discussed this topic
with administrators and track and human factor discipline specialists
from each of these regional offices. We conducted these interviews on-
site at the offices located in Fort Worth, Texas, and Chicago,
Illinois. We also discussed this topic with officials from the three
state regulatory associations employing the greatest number of railroad
safety inspectors in order to discuss how state inspectors coordinate
their activities with FRA inspectors. (See the end of this appendix for
a list of organizations that we contacted.) We also examined our
published work on risk management and safety oversight approaches used
by other modal administrations within the Department of Transportation
as well as some other organizations responsible for overseeing rail
safety.
We reviewed FRA data on its inspection activities for the period from
1996 through 2005. To assess the reliability of the inspection data, we
(1) performed electronic testing of required data elements, (2)
reviewed existing information about the data and the system that
produced them, and (3) interviewed agency officials knowledgeable about
the data. We discussed our preliminary results with FRA to ensure that
we were capturing the correct information and consulted with these
officials to resolve questions on the data collection process. We
determined that the data were sufficiently reliable for the purposes of
this report.
To determine how FRA assesses the impact of its oversight efforts in
improving safety, we examined the methods FRA uses to assess the
results of its oversight programs and FRA's use of this information to
make decisions about its oversight strategy. As part of this effort, we
reviewed FRA documents on its safety performance measures and
evaluations of its oversight and enforcement activities. We also
discussed this issue with managers at headquarters and in the regional
offices responsible for developing and using performance information.
In addition, we reviewed our recommendations on performance
measurement, the use of performance information, and program evaluation
and determined the extent to which FRA's practices are consistent with
these recommendations.
We focused our work on FRA's oversight activities aimed at reducing
train accidents-such as train collisions and derailments-rather than
those aimed at reducing highway-rail crossing and trespassing
accidents. FRA's oversight of highway-rail grade crossing safety has
been the subject of two recent Department of Transportation Inspector
General audits. In addition, both these types of accidents and
trespassing accidents involve issues not related to railroad safety
performance, such as driver awareness of grade crossing safety and
individuals' willingness to abide by railroads' warning signs on their
property. We also focused on FRA's oversight of railroads rather than
its oversight of non-railroad companies (such as shippers of hazardous
materials by rail) because the agency 's oversight efforts focus
primarily on railroads. In addition, according to FRA, most recent
serious train accidents involving the release of hazardous materials
have resulted from problems with railroad operations.
Other Aspects of Our Work:
We also examined how FRA uses enforcement and other methods for
ensuring that safety problems on railroad systems are resolved. In
order to do this, we reviewed FRA's policies, procedures, and guidance
for conducting enforcement; major enforcement actions such as
compliance agreements; Railroad Safety Oversight program documents; and
other agency documents. We also discussed FRA's approaches to resolving
safety problems, through enforcement and other means, with officials
from FRA headquarters, Railroad System Oversight managers, and
administrators and inspection discipline specialists in three regional
offices. Regarding FRA's enforcement approach, we reviewed how FRA
employs enforcement to improve safety on railroads' systems. However,
we could not determine the extent to which railroads address systemic
safety problems as a result of enforcement because FRA does not track
the broad-scale safety problems it identifies or the extent to which
these problems are resolved. We focused on FRA's use of enforcement as
part of its overall oversight strategy and did not examine the agency's
individual enforcement actions.
We also obtained FRA data on civil penalties from FRA's enforcement
database, which includes data on assessed and collected amounts from
1996 through 2005. We assessed the reliability of the enforcement data
by the same means that we employed to assess the reliability of FRA's
inspection data. We determined that the enforcement data used in this
report were sufficiently reliable for the purposes of this report.
Finally, we met with or contacted the following organizations or
persons in order to obtain a fuller understanding of railroad safety
issues and obtain their perspectives on FRA's oversight approach.
Other federal agencies:
National Transportation Safety Board:
Freight railroads (Class I):
BNSF Railway Company:
CSX Transportation, Inc.
Norfolk Southern Railway Company:
Union Pacific Railroad Company:
Passenger railroads:
National Railroad Passenger Corporation, or Amtrak:
Northeast Illinois Regional Commuter Rail Corporation, or Metra:
New Jersey Transit Rail Operations:
Regional and short line railroad management companies:
Cedar American Rail Holdings, Inc.
RailAmerica:
Industry associations:
American Chemistry Council:
Association of American Railroads:
American Public Transportation Association:
American Short Line and Regional Railroad Association:
Labor unions:
AFL-CIO Brotherhood of Maintenance of Way Employees:
Brotherhood of Locomotive Engineers and Trainmen:
United Transportation Union:
State oversight organizations:
Association of State Rail Safety Managers:
California Public Utilities Commission:
Ohio Public Utilities Commission:
Texas Department of Transportation:
Canadian oversight organization:
Transport Canada:
Academic expert:
Dr. Ian Savage, Department of Economics, Northwestern University:
[End of section]
Appendix II: FRA Addresses Safety Problems through Cooperation and
Enforcement:
FRA uses cooperation with railroads and enforcement actions in various
ways to resolve identified safety problems and achieve compliance. When
inspectors find problems during inspections, FRA's policy is to cite
defects for most instances of noncompliance and to encourage the
railroad to comply voluntarily. For example, issues may be addressed on
site with railroad officials during inspections. According to FRA
officials, railroads often correct identified problems immediately and
if so, these problems would not require additional action. When
railroads do not comply voluntarily or the identified defects are
serious, FRA may cite violations and recommend civil penalties or take
other enforcement actions--either against railroads or individuals--to
promote compliance with safety regulations.[Footnote 69] According to
FRA officials, inspectors follow up on violations or high numbers of
defects within 60 days to ensure that they are corrected.[Footnote 70]
FRA most commonly uses civil penalties against companies as its
enforcement tool for site-specific violations.[Footnote 71] From
January 2005 through July 2006, FRA assessed about 8,600 violations for
civil penalties. FRA has other enforcement tools. These include
compliance agreements and compliance orders, civil penalties against
individuals, special notices for repair, emergency orders, criminal
penalties, disqualification orders, and injunctions. (See table 4.) FRA
uses these tools much less frequently than it does civil penalties. For
example, FRA issued 288 special notices for repair, 118 warning letters
and fewer than a dozen of all other enforcement actions during this
period.[Footnote 72]
Table 4: Description of FRA Enforcement Actions and Frequency of Use,
January 2005 through July 2006:
Enforcement action: Civil penalty against a railroad or other entity
except for an individual;
Number of times used: 8,606;
Description: Imposes a monetary penalty on a railroad or other entity,
such as a company that ships hazardous materials by rail, that violates
a rail safety or hazardous materials statute, regulation, or order.
Each day that the violation continues is a separate violation.
Enforcement action: Special notice for repair;
Number of times used: 288;
Description: Orders a locomotive, freight car, or passenger car out of
service and may require a reduction of the maximum operating speed over
defective track segments.
Enforcement action: Warning letter to an individual;
Number of times used: 118;
Description: Informs an individual that FRA believes that the
individual has committed a rail safety or hazardous materials violation
and that any future violation by the individual will result in
enforcement action.
Enforcement action: Civil penalty against an individual;
Number of times used: 6;
Description: Imposes a monetary penalty on any individual who willfully
violates or willfully causes the violation of a rail safety statute,
regulation, or order.
Enforcement action: Compliance agreement;
Number of times used: 2;
Description: States a railroad's agreement to take a specified action
to promote compliance. The railroad agrees that if, in FRA's judgment,
the required action is not performed, the railroad will not contest
FRA's sanction-typically a compliance order. See below.
Enforcement action: Criminal penalty;
Number of times used: 1;
Description: Imposes (1) either a monetary penalty or imprisonment for
up to 2 years, or both, on an individual for knowingly and willfully
violating certain reporting, recordkeeping, or other regulations or (2)
a monetary penalty or imprisonment for up to 5 years, or both, for
knowingly violating the hazardous materials statute or an implementing
regulation or order.
Enforcement action: Disqualification order;
Number of times used: 1;
Description: Prohibits an individual from performing safety- sensitive
functions in the rail industry for a specified period if the
individual's violation of a rail safety statute or regulation
demonstrates unfitness to perform such functions.
Enforcement action: Emergency order;
Number of times used: 1;
Description: Orders corrective action where an unsafe condition or
practice causes an emergency situation involving a hazard of death or
personal injury.
Enforcement action: Compliance order;
Number of times used: 0;
Description: Directs compliance following repeated failure to comply
with rail safety or hazardous material statute or regulation.
Enforcement action: Injunction;
Number of times used: 0;
Description: Restrains a violation of, or enforces, a rail safety or
hazardous materials regulation or order.
Source: FRA.
[End of table]
FRA inspectors cite many defects, but cite comparatively few of these
defects as violations warranting enforcement action. Since 1996, FRA
inspectors have cited an average of about 4 violations for every 100
defects cited annually. According to FRA officials, inspectors cite
relatively few defects as violations warranting enforcement action
because FRA's focused enforcement policy guides inspectors to cite
violations only for problems that pose safety risks. In addition,
inspectors have discretion in citing a defect or a violation for a
given instance of noncompliance--FRA directs inspectors to first seek
and obtain the railroads' voluntary compliance with the rail safety
regulations.
According to FRA officials, inspectors usually choose to provide the
railroad with information about defects they found during their
inspection, discuss these instances of noncompliance, and attempt to
obtain the railroad's commitment to improve compliance. If the
railroad's response is inadequate or the inspector finds that the
problem warranting the defect is serious, the inspector may exercise
the agency's enforcement discretion by citing a violation, recommending
that FRA take enforcement action, generally a civil penalty. The agency
makes an initial penalty assessment against the railroad based on the
type of violation that occurred.[Footnote 73] FRA meets with the major
railroads in an annual settlement meeting to negotiate a final amount
for all civil penalties cited in the past year. This amount is based on
the railroad's compliance history and efforts to correct the problem,
among other factors.[Footnote 74] The total value of civil penalties
assessed and collected each year was higher from 2001 through 2005 than
from 1996 to 2000. (See fig. 10.) According to FRA officials, the
higher civil penalty assessments after 2000 reflect the agency's
efforts to focus its inspection activity on areas that present the
greatest risk. FRA officials also told us that when the agency
initiated the Safety Assurance and Compliance Program--which emphasized
a partnership approach with railroads to improve safety--in 1995,
inspectors initially cited fewer violations. They noted that in 2001
FRA's management pushed for inspectors to be more aggressive in citing
violations. Since 2001, the amounts collected have been about 63
percent of the amounts initially assessed. Consistent with the purpose
of the federal railroad safety laws and with federal court decisions
interpreting the purpose of such laws, the agency's goals are to
promote safety and to gain compliance rather than to maximize amounts
collected. For example, FRA may agree to a reduced penalty amount if
the railroad immediately remedies the safety problem or implements a
new program to prevent a problem from recurring.[Footnote 75] This is
consistent with federal law. In other cases, FRA will agree to a
reduced penalty amount if its documentation on the violation is not
substantial enough.
Figure 10: FRA's Civil Penalties, 1996 through 2005, in 2005 Dollars:
[See PDF for image]
Source: GAO analysis of FRA data.
Notes: Individual penalties resulting from violations are consolidated
into one or more case(s) for each railroad and are negotiated annually
with FRA and the railroad during settlement conferences.
Each year's amounts are for cases initiated in that year. Some
penalties may be initially assessed in one year, with the final
assessment in another year. FRA, in commenting on a draft of our
report, provided 2006 civil penalty figures. However, we did not use
this information because there was not enough time to assess its
reliability before the report was issued.
Penalties against individuals are not included. From 1996 through 2005,
FRA issued an average of 1 civil penalty per year against individuals.
[End of figure]
FRA seeks to resolve broad-scale compliance problems it has identified
by first discussing them with railroad officials and elevating them, as
necessary, to obtain an appropriate response. After in-depth inspection
efforts at multiple sites, inspectors meet with railroad managers
responsible for those sites to discuss overall findings or problems.
For very serious or systemic problems, FRA may ask railroads to submit
corrective action plans and may review these plans for adequacy. FRA
sometimes discusses broad problems with railroad headquarters officials
to try to obtain corrective actions. For example, one regional
administrator told us that his region arranged a multiregion meeting
with the senior management of a Class I railroad to discuss systemic
problems with the railroad's equipment. FRA asked the railroad to
submit a corrective action plan to address the equipment problems.
According to FRA officials, the railroad has been meeting the
milestones in the corrective action plan and has been making progress
in addressing its equipment problems. Also, FRA's Railroad System
Oversight managers, who act as liaisons with the Class I railroads,
help to maintain frequent communication with these railroads about
major problems that have been identified and associated corrective
actions. These efforts to cooperate with railroads to resolve problems
may be combined with civil penalties for violations found at specific
locations. According to FRA officials, when in-depth inspections result
in findings of serious problems, inspectors always follow up to
determine whether these problems are adequately resolved. However, FRA
has no central repository for data on the status of these broader
problems its inspectors have identified at railroads.
FRA officials told us that they hold frequent internal discussions
among headquarters and regional management about these broad-scale
compliance problems that have been identified--whether local, regional,
or systemwide--and actions that the agency should take to attempt to
resolve them. According to FRA officials, the agency sometimes uses
compliance agreements, which require railroads to take significant
actions beyond those specifically required by regulations to improve
their ability to comply, when broad-scale compliance problems are
egregious and have not been resolved through other methods. Compliance
agreements allow FRA to apply more leverage in trying to obtain
compliance because FRA uses the agreements as an alternative to the
railroad involved undergoing an FRA proceeding for a compliance order.
For example, under recent compliance agreements, railroads have agreed
to reinstruct managers on how to test employees' adherence to operating
rules and to develop and implement track maintenance plans to eliminate
systemic track defects. FRA monitors railroads' performance under these
agreements. In some instances, FRA has also used compliance orders to
address significant railroad compliance problems. However, these
enforcement tools are seldom used. FRA has entered into 13 compliance
agreements altogether and one compliance order since 1996, or an
average of about 1 per year. In comparison, since 1996, FRA has
assessed in the neighborhood of almost 40,000 violations for civil
penalties.
This approach to resolving broad-scale safety problems has had some
success. For example, the three railroads that have entered into
compliance agreements in the past 2 years have generally made progress
in improving compliance, according to the results of FRA's follow-
up.[Footnote 76] In addition, FRA officials have cited a number of
other successes, including improved compliance by several railroads
with signal inspection and testing requirements,[Footnote 77] and
another railroad's implementation of an electronic system to record
locomotive defects and repairs following FRA's finding that inadequate
recordkeeping had resulted in the operation of locomotives with
multiple defects. FRA's Railroad System Oversight managers have also
worked with railroads to make some systemic safety improvements not
related to compliance. For example, these managers have encouraged
railroads to make improvements related to roadway worker communication,
signal maintenance, and mentoring of new employees.
[End of section]
Appendix III: Oversight of Risk Management in the U.S. Commuter
Railroad, U.S. Pipeline, and Canadian Railroad Industries:
Risk management is a systematic process for assessing risks and taking
appropriate steps to deal with them. It is founded on several
inspection disciplines, including financial economics, decision
science, organizational theory, and strategic management. The National
Academy of Sciences, a presidential commission, private organizations,
and others have addressed the subject and have recognized its
applicability in both the private and the public sectors. We have
developed a framework for risk management based on industry best
practices.[Footnote 78] This framework divides risk management into
five major phases. (See table 5.)
Table 5: Risk Management Framework:
Phase: Strategic goals, objectives, and constraints;
Description: Establish an organization's strategic goals and the steps
needed to attain those results, including performance measures to
assess progress. Constraints that affect outcomes can also be
identified during this phase.
Phase: Risk assessment;
Description: Assess the threats to and vulnerabilities of assets so
that countermeasures may be instituted to prevent or mitigate risks.
Risks can be assessed by various methods, depending on the specific
application and knowledge available.
Phase: Alternatives evaluation;
Description: Evaluate risk reduction methods by considering the
countermeasures and the costs and benefits associated with each.
Countermeasures can be considered and prioritized according to a number
of factors, such as the degree of risk reduction they afford and the
cost and difficulty to implement them.
Phase: Management selection;
Description: Choose among alternative actions. Management's active
participation is important at this phase because risk assessment tools
contain various assumptions about preferences that may require value
judgments and review at the management level.
Phase: Implementation and monitoring;
Description: Move from planning to implementing the selected
countermeasures. Following implementation, monitoring is essential to
help ensure that the entire risk management process remains current and
relevant.
Source: GAO.
[End of table]
During the last 10 years, the American Public Transportation
Association (APTA), Pipeline and Hazardous Materials Safety
Administration (PHMSA), and Transport Canada have developed and
implemented new approaches for overseeing safety in the U.S. commuter
railroad, U.S. pipeline, and Canadian railroad industries,
respectively. These approaches promote the use of risk management and
incorporate various elements of risk management noted above. They also
complement traditional compliance inspections.
In 1996, following two serious commuter rail accidents, APTA, with FRA
support, started a program to help its 16-member commuter railroad
properties develop and implement plans for managing the safety of their
systems. APTA had previously developed a similar program for the rapid
transit industry. Risk management is a key aspect of these plans, which
must include, among other things, goals and objectives, the
identification of hazards, an assessment of their associated risks, the
analysis and implementation of actions to reduce these risks, and
internal assessments of the effectiveness of safety management.
Commuter railroads are given the latitude to develop individual plans
that conform to APTA's guidelines but that are based on their unique
circumstances. APTA audits its member railroads' system safety
management plans on a 3-year cycle. During the first year, APTA
conducts an initial assessment of the plan; during the second year,
APTA evaluates how well the railroad implements its plan; and during
the third year, APTA follows up with the railroad to see what actions
it has taken in response to APTA's audit findings.
In 2000, to better focus on safety risks that are unique to individual
pipelines, PHMSA, then operating as the Office of Pipeline Safety,
issued the first in a series of integrity management regulations that
now apply to more than 1,000 hazardous liquid and gas transmission
pipelines operating in densely populated and environmentally sensitive
areas. Under this approach, operators are required to develop programs
to systematically assess and mitigate safety threats, such as
corrosion, to pipelines located in such high-risk areas. For example,
these programs must integrate all available information about pipeline
integrity and the consequences of a leak or rupture, repair identified
defects within defined time limits based on their severity, and
evaluate the need for additional preventive and mitigating actions. In
addition, operators are required to report program performance measures
to PHMSA semi-annually. PHMSA inspects these written programs as well
as their implementation in periodic comprehensive inspections.
During the 1990s, a series of derailments raised concerns over the
level of safety in the Canadian rail industry. In 2001, following a
review of its oversight approach, Transport Canada determined that a
more comprehensive safety management assessment was necessary to
minimize safety risks, and adopted new safety management regulations
under Canada's Railway Safety Act. The new regulations require that
Canadian railway companies develop their own safety management systems,
subject to Transport Canada's review. These systems must include, among
other things, annual safety performance targets; the identification of
safety issues through a variety of methods (such as analyses of safety
data and input from employees); an assessment of the risks associated
with these issues to determine their significance; the development,
approval, and implementation of strategies for controlling these risks;
and systems for monitoring these strategies and other management-
approved corrective actions. Transport Canada audits the railroads'
documentation and implementation of their safety management systems.
The level of such monitoring varies depending on the safety performance
of the railroad.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Katherine Siggerud (202) 512-2834 or siggerudk@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, James Ratzenberger, Assistant
Director; Ashley Alley; Marianne Anderson; Timothy Bober; Elizabeth
Eisenstadt; Judy Guilliams-Tapia; Brandon Haller; Bonnie Pignatiello
Leer; Masha P. Pastuhov-Purdie; and Minette Richardson made key
contributions to this report.
FOOTNOTES
[1] See U.S. Department of Transportation, Office of the Inspector
General, Audit of Oversight of Highway-Rail Grade Crossing Accident
Reporting, Investigations and Safety Regulations, MH-2006-016
(Washington, D.C., Nov. 28, 2005); and Report on the Audit of the
Highway-Rail Grade Crossing Safety Program, MH-2004-065 (Washington,
D.C., June 16, 2004).
[2] Generally, human factors are behaviors that affect job performance,
such as incorrectly setting switches. According to FRA, the term human
factors refers broadly to the role of human participation in any system
and to the ways in which human beings positively or negatively
contribute towards system performance.
[3] This figure is an FRA estimate, based on an estimation of the
amount of activity, such as train movements, on each railroad in the
United States.
[4] Risk is the combination of the likelihood and the consequence of a
specified hazard being realized.
[5] A train mile is the movement of a train a distance of 1 mile.
[6] For 2005, the Surface Transportation Board has defined Class I
railroads as railroads earning adjusted annual operating revenues of
$319.3 million or more. Class II railroads are those earning between
$25.5 million and $319.3 million, and Class III railroads are those
earning less than $25.5 million.
[7] FRA defines a train accident as any collision, derailment, fire,
explosion, act of God, or other event involving operation of railroad
on-track equipment (standing or moving) that results in reportable
damages greater than the current reporting threshold to railroad on-
track equipment, signals, track, track structures, and roadbed. The
threshold for 2006 was $7,700.
[8] In addition, according to FRA, train accident rates for 2006 will
probably appear slightly more favorable than those for 2005 because of
a single, large increase in the dollar level reporting threshold for
the year 2006. Specifically, starting in 2006, railroads are required
to report accidents resulting in railroad property damage exceeding
$7,700, up from the previous threshold of $6,700.
[9] Nonsignaled territory refers to sections of track where no signal
or other system is in service that indicates that a main track switch
may be in other than its normal position.
[10] A processor-based train control system or product is one that is
dependent for its proper functioning on a digital processor, such as an
onboard signal or switch control.
[11] For example, FRA conducts twice yearly training seminars for short
line railroads on how to comply with its regulations and operate
safely.
[12] This number does not include contractor employees hired by the
railroads.
[13] The National Rail Safety Action Plan also includes initiatives to
improve hazardous materials safety and emergency response capability.
Most of the serious accidents involving the release of hazardous
material that have occurred in the last several years have been caused
by human factors or track defects.
[14] According to FRA, a close call is an opportunity to improve safety
practices in a situation or incident that has a potential for more
serious consequences. It represents a situation in which an ongoing
sequence of events was stopped from developing further, preventing the
occurrence of potentially serious safety-related consequences.
[15] Other key agency plans that focus efforts on the highest priority
risks related to train accidents include the department's rulemaking
agenda, strategic plan and annual performance plan, and FRA's
performance budget. The rail safety goals and measures contained in the
performance plan and performance budget are discussed later in this
report.
[16] Management decisions at the organizational level, such as
decisions regarding the allocation of resources or crew scheduling, can
have consequences in the workplace that can contribute to human factor
accidents.
[17] Derails are devices used to prevent the obstruction of track by
unauthorized movements of trains or unattended rolling stock.
[18] Most Class I railroads use one of two sets of standard rules: the
Northeast Operating Rules Advisory Committee rulebook and the General
Code of Operating Rules. Railroads must file their operating rules with
FRA.
[19] In a few cases, FRA's regulations do require some practices, such
as securing a sufficient number of handbrakes, that are in railroad
operating rules. Also, the Switching Operations Fatality Analysis
working group--made up of representatives of FRA, unions, railroads,
and the Department of Transportation's Volpe National Transportation
Systems Center--studies fatalities that occur to workers engaged in
switching operations and recommends ways that such events can be
prevented.
[20] The law also specifies that train employees are required to have
10 consecutive hours off duty following 12 continuous hours on duty.
[21] NTSB, Collision of Union Pacific Railroad Train MHOTU-23 With BNSF
Railway Company Train MEAP-TUL-126-D With Subsequent Derailment and
Hazardous Materials Release, Macdona, Texas, June 28, 2004, Railroad
Accident Report NTSB/RAR-06/03 (Washington, D.C., 2006).
[22] According to FRA, it is the only safety regulatory agency in the
Department of Transportation that lacks regulatory authority over
worker duty hours.
[23] Risk is the combination of the likelihood and the consequence of a
specified hazard (or threat) being realized. We have developed a
framework for risk management based on industry best practices. See
app. III for a discussion of this framework as well as comprehensive
risk management approaches in use by several other transportation
agencies for overseeing the U.S. commuter railroad, U.S. pipeline, and
Canadian railroad industries.
[24] In reviewing the Voluntary Protection Program of the Occupational
Safety and Health Administration, along with several other voluntary
compliance programs, we found that benefits reported by participating
worksites included reduced injury and illness rates, an improved safety
culture, and improved employee-management relations. See GAO, Workplace
Safety and Health: OSHA's Voluntary Compliance Strategies Show
Promising Results, but Should Be Fully Evaluated before They Are
Expanded, GAO-04-378 (Washington, D.C.: Mar. 19, 2004).
[25] FRA has also recently issued standards for processor-based
positive train control systems. These systems are an advanced train
control technology that can prevent train collisions through automatic
brake applications. They also can provide enhanced protection for
maintenance-of-way workers.
[26] FRA also has two additional automated track inspection vehicles
that are primarily used for research activities but occasionally are
used for inspections.
[27] However, FRA may inspect some sections of track more than once a
year.
[28] FRA also has a number of other ongoing efforts to improve track
inspection capabilities. For example, since 2002 it has sponsored a
Rail Integrity Task Force--composed of experts in the railroad
industry, FRA, and the Department of Transportation's Volpe National
Transportation Systems Center--to identify best practices for rail
inspection, maintenance, and replacement.
[29] In continuous welded rail track, rails are welded together to form
one continuous rail that may be several miles long. There may be joints
in this rail for several reasons, including the need for insulated
joints that electrically separate track segments for signaling purposes
and the need to replace a section of defective rail.
[30] We did not evaluate these models or the data on which they are
based. FRA defines train incidents as events involving the movement of
railroad equipment that results in a casualty but does not cause damage
above the reporting threshold established for train accidents, which
was $7,700 in 2006.
[31] FRA provides training for state inspectors and certifies them as
qualified to perform inspections and cite violations.
[32] Overall, the motive power and equipment discipline currently has
the highest number of inspectors (86), followed by the operating
practices discipline (76), the track and structures discipline (73),
the signal and train control discipline (61), and the hazardous
materials discipline (55). However, to help reduce human factor
accidents, which account for the highest percentage of train accidents,
inspectors in the motive power and equipment discipline conduct some
inspections of operating practices.
[33] These figures do not include railroad contractor employees or
track that is not in use.
[34] Inspectors also sometimes travel along part of a railroad's system
in conducting inspections. According to FRA, from 2002 to 2005,
inspectors traveled between two locations in 17 percent of the routine
inspections of railroads.
[35] However, in some cases, FRA conducts nationwide inspections of
railroads' compliance with specific requirements. For example, in mid-
2006, it began a set of nationwide inspections of various railroads'
compliance with requirements for notifying train crews of the types of
hazardous materials being transported on their trains, after
identifying noncompliance in this area as a problem.
[36] This number includes inspections of railroads as well as of
nonrailroads (companies that ship hazardous materials by rail, tank car
manufacturers, and tank car repairers). In 2005, inspections of
nonrailroads represented 7 percent of all inspections.
[37] To help reduce accidents caused by human factors, which are the
leading cause of train accidents, FRA's motive power and equipment
inspectors conduct some inspections to look for operating practices
problems that can lead to these types of accidents.
[38] FRA officials have explained that operating practices inspectors
have had a limited ability to cite defects and violations because of
the way regulations in this area are written. For example, as noted
previously, the regulations contain general requirements about
railroads' programs for inspecting employees' adherence to operating
rules and do not specifically require that employees follow these
rules. The agency expects that its proposed regulations on operating
rules will improve its ability to enforce in this area, because the
requirements will be more stringent than existing regulations.
[39] App. II contains a description of FRA's efforts to resolve such
problems through discussions with railroad officials as well as
enforcement actions. According to FRA officials, the agency uses
compliance agreements, which require railroads to take significant
actions to improve their ability to comply, when broad-scale compliance
problems are egregious and have not been resolved through other
methods. FRA has issued eight such agreements since 2000. These
agreements have mainly focused on compliance problems in the operating
practices and track disciplines.
[40] According to FRA officials, its ability to track broad-scale
compliance problems is limited because its existing databases related
to safety are not integrated. The agency has an effort underway to
better integrate its existing data. The next section contains a
description of this effort.
[41] The Railroad System Oversight managers track the status of
nonregulatory problems, as well as some regulatory problems, that they
are working on and, in response to our request, created papers for us
describing systemwide and regional issues for each of the Class I
railroads. In addition, these managers produce quarterly and annual
reports showing safety trends--based mainly on accident data--for each
of the Class I railroads.
[42] Risk is the combination of the likelihood and the consequence of a
specified hazard being realized. In risk management, the term "threat"
is sometimes used in place of hazard.
[43] GAO, Risk Management: Further Refinements Needed to Assess Risks
and Prioritize Protective Measures at Ports and Other Critical
Infrastructure, GAO-06-91 (Washington, D.C.: Dec. 15, 2005); Homeland
Security: Summary of Challenges Faced in Targeting Oceangoing Cargo
Containers for Inspection, GAO-04-557T (Washington, D.C.: Mar. 31,
2004); and Rail Security: Some Actions Taken to Enhance Passenger and
Freight Rail Security, but Significant Challenges Remain, GAO-04-598T
(Washington, D.C.: Mar. 23, 2004).
[44] APTA is a nonprofit organization representing the transit
industry, including U.S. commuter rail systems. APTA offered to develop
this program after FRA directed passenger railroads to develop system
safety plans for addressing hazards associated with passengers
occupying the lead units of a train. The APTA program is more extensive
and is intended to cover all aspects of system safety. FRA issued this
directive in 1996, in an emergency order, after two passenger train
accidents caused 14 deaths.
[45] PHMSA administers the national regulatory program to ensure the
safe transportation of hazardous liquids and natural gas by pipeline.
PHMSA and FRA are similar in several respects. For example, both
oversee large industries with relatively few inspectors. Both also
oversee industries that have relatively few deaths, injuries, and
accidents (as compared to transportation as a whole), making additional
safety gains more difficult.
[46] Transport Canada oversees the safety and security of Canada's
rail, marine, highway, and aviation operations.
[47] In addition, the European Commission has funded an effort to
develop proposed guidelines for a safety management system for rail
companies of its member nations. These proposed guidelines recommend
that European railways incorporate some basic risk management elements-
-including safety performance targets, risk assessment and control, and
an internal audit process--in their safety management systems. See E.M.
El Koursi, L. Tordai and J. Rodriguez. European Commission Fifth
Framework Programme, SAMNET Thematic Network, SAMNET Synthesis Report,
Safety Management and Interoperability (SAMNET, February 2006).
[48] GAO, Natural Gas Pipeline Safety: Integrity Management Benefits
Public Safety, but Consistency of Performance Measures Should Be
Improved, GAO-06-946 (Washington, D.C.: Sept. 8, 2006).
[49] As noted previously, FRA enforces PHMSA's hazardous material
regulations as they relate to the transportation of such materials by
rail. Specifically, under this proposed regulation, which was issued in
December 2006, railroads would be required to compile annual data on
certain shipments of hazardous materials that are particularly
hazardous, use the data to analyze safety and security risks along the
rail transportation routes where those materials are transported,
assess alternative routing options, and base routing decisions on those
assessments.
[50] FRA has also worked with Amtrak, which does not participate in
APTA's program, to assist it in developing a system safety plan that is
consistent with APTA's guidelines.
[51] We have reported that agencies should create a set of performance
goals that address important and various aspects of program
performance. See, for example, GAO, Results-Oriented Government: GPRA
Has Established a Solid Foundation for Achieving Greater Results, GAO-
04-38 (Washington, D.C.: Mar. 10, 2004); Managing for Results:
Strengthening Regulatory Agencies' Performance Management Practices,
GAO/GGD-00-10 (Washington, D.C.: Oct. 28, 1999); and Agency Performance
Plans: Examples of Practices That Can Improve Usefulness to
Decisionmakers, GAO/GGD/AIMD-99-69 (Washington, D.C.: Feb. 26, 1999).
[52] A number of other agency efforts--including the Railroad Safety
Oversight program, the development of new safety standards, rail-
related research and development, and initiatives to improve highway-
rail grade crossing safety--also contribute toward these end outcomes.
[53] We have suggested that regulatory programs develop logic models to
develop a better understanding of how their programs deliver results,
in order to select appropriate performance goals and measures. See GAO-
04-38 and GAO/GGD-00-10.
[54] This act is the centerpiece of a statutory framework that Congress
put in place during the 1990s to help resolve the long-standing
management problems that have undermined the federal government's
efficiency and effectiveness and to provide greater accountability for
results. See GAO-04-38.
[55] See GAO/GGD/AIMD-99-69 and GAO/GGD-00-10.
[56] For violations determined by the inspector to require corrective
action, railroads are required to provide FRA with a report within 30
days of the end of that month on the corrective actions they have
taken. These reports also include the type of action taken, such as
repair or replacement of equipment and disciplinary action or training
of employees. FRA tracks whether these reports are received on time as
well as the types of actions taken.
[57] FRA's inspection reports contain a field for recording the receipt
of railroads' reports on corrective actions but do not contain a field
for recording whether inspectors have determined, in following up on
violations, that the corrective actions are adequate. Furthermore, some
regional staff told us that inspectors do not consistently record
follow-up inspections as such.
[58] In contrast, defects and violations tend to be much more specific.
In this case, inspectors also found numerous defects concerning
specific instances of track not meeting federal standards and two
violations concerning defects that had gone for more than 30 days
without corrective action.
[59] In fiscal year 2006, FRA compiled information for the first time
on all in-depth inspection activity by its headquarters and regional
offices into one report and began producing quarterly updates on the
status of these inspections. These updates contain some information on
findings of broad-scale problems, in narrative form, but do not provide
overall assessments of progress being made by each railroad as a whole
in addressing these problems.
[60] However, FRA does include in its quarterly review of Class I
railroads' performance trends certain operating practices and track
defect rates that it has found to be related to accident rates.
[61] We have reported on such challenges and how agencies have overcome
them. See, in particular, GAO-04-38; GAO/GGD-00-10; Managing for
Results: Measuring Program Results That Are Under Limited Federal
Control, GAO/GGD-99-16 (Washington, D.C.: Dec. 11, 1998); and Managing
for Results: Regulatory Agencies Identified Significant Barriers to
Focusing on Results, GAO/GGD-97-83 (Washington, D.C.: June 24, 1997).
[62] FRA has tasked a contractor with developing a plan for a data
warehousing strategy for the agency that will integrate its data from
various sources. According to agency officials, this initiative will
allow FRA to better monitor its performance, through, for example,
providing scorecards and graphical tools to depict performance.
[63] A major concern with the previous Safety Assurance and Compliance
Program, which ended in 2005, was that systemwide safety problems
handled under this program took too long to resolve.
[64] Such evaluations can also help determine the extent to which a
program is having an impact on these outcomes versus other variables
that affect outcomes. See GAO-04-38.
[65] See GAO, Program Evaluation: An Evaluation Culture and
Collaborative Partnerships Help Build Agency Capacity, GAO-03-454
(Washington, D.C.: May 2, 2003); and Program Evaluation: Studies Helped
Agencies Measure or Explain Program Performance, GAO/GGD-00-204
(Washington, D.C.: Sept. 29, 2000).
[66] U.S. Department of Transportation-Office of the Inspector General,
Review of Allegations that FRA Deputy Administrator Attempted to Relax
Safety Enforcement Against Union Pacific (Washington, D.C., Dec. 10,
2004); and Audit of Oversight of Highway-Rail Grade Crossing Accident
Reporting, Investigations, and Safety Regulations, MH-2006-016
(Washington, D.C., Nov. 28, 2005).
[67] The Office of Management and Budget performed this assessment
using its Program Assessment Rating Tool. This tool examines factors
that affect and reflect program performance, including program purpose
and design, performance measurement and evaluations, and aspects of
program management.
[68] The Railroad Safety Board approves or denies requests for waivers
or special approval submitted by railroads and other parties subject to
FRA regulations.
[69] While we reviewed how FRA employs enforcement to improve safety on
railroads' systems, we could not determine the extent to which
railroads address systemic safety problems as a result of enforcement.
This is because FRA does not track the broad-scale safety problems it
identifies or the extent to which these problems are resolved. We
focused on FRA's use of enforcement as part of its overall oversight
strategy and did not examine the agency's individual enforcement
actions.
[70] Often, an inspector will conduct follow-up re-inspections during
other routine inspections. However, an inspector may make a special
visit to conduct follow-up if warranted.
[71] FRA's Statement of Enforcement Policy specifies that before citing
violations and recommending penalties, inspectors consider the
seriousness of the condition or act, the potential safety hazard posed
by the condition or act, and the current level of compliance of the
offending person (e.g., a railroad or individual), among other things.
[72] FRA could not supply data covering a longer period on the
frequency of use of all of its enforcement actions without substantial
effort.
[73] In December 2006, FRA published in the Federal Register proposed
amendments to its schedules of civil penalties for each type of
violation to ensure that penalty amounts more fully reflect the risk
associated with a railroad's violation of the rail safety regulations.
[74] Given the volume of civil penalty cases, FRA usually negotiates
civil penalties with smaller railroads and shippers through the mail
and telephone conferences. FRA is authorized to negotiate civil
penalties with railroads and exercises this authority by annually
settling civil penalty amounts with each railroad. The criteria for
compromising with railroads on civil penalty amounts are set in
statute. In determining the amount of a compromise, the Secretary shall
consider (1) the nature, circumstances, extent, and gravity of the
violation; (2) with respect to the violator, the degree of culpability,
any history of violations, the ability to pay, and any effect on the
ability to continue to do business; and (3) other matters that justice
requires.
[75] The Federal Motor Carrier Safety Administration follows a similar
policy. See GAO, Large Truck Safety: Federal Enforcement Efforts Have
Been Stronger Since 2000, but Oversight of State Grants Needs
Improvement, GAO-06-156 (Washington, D.C.: Dec. 15, 2005).
[76] FRA's compliance agreements with three different divisions of one
Class I railroad have resulted in improved compliance. FRA had to
extend the compliance agreement with the third division because
noncompliance continued but has since terminated the compliance
agreement because of improved safety performance. While FRA does not
have overall measures of compliance, it sometimes, in summary reports
on follow-up inspections at a railroad, records trends in certain types
of defects found.
[77] FRA has noted instances of significant noncompliance with signal
inspection and testing requirements on the part of two major commuter
railroads and at least one Class I railroad.
[78] To develop the framework, we reviewed risk management literature,
our reports and testimonies on this topic, and other government
guidance. In addition, we consulted with experts on risk management,
risk modeling, and terrorism. We reviewed numerous frameworks from
industry, government and academic sources. We field-tested the
framework, and it was reviewed by academic experts in risk management.
See GAO-06-91.
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