Review of the Federal Railroad Administration’s Research and Development Program (2020)

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37 3 Human Factors The Human Factors Division’s research is organized in two general areas, each consisting of subareas of work. One of the two general areas concerns the human performance of locomotive engineers, train crews, maintenance- of-way workers, and other railroad personnel who can affect the safe operation of trains and the safe condition of track. The other concerns the prevention of grade-crossing incidents, suicides, and trespasser injuries and fatalities. The stated strategic priorities for this work are understand- ing and managing worker fatigue and distraction; addressing human error through automation and improved human automation interaction; develop- ing, implementing, and evaluating strategies to mitigate trespass and suicide incidents; investigating technologies to improve grade-crossing safety and motorists’ behavior at grade crossings; and strengthening the safety and organizational culture of railroad organizations. The division employs sev- eral methods to carry out this research, including survey research, human subjects’ simulator experiments, technology demonstrations, pilot studies with railroads, and funding support for safety culture assessments and training of small railroads. This chapter is organized in a manner similar to that of the other chap- ters that examine the four divisions of the Office of Research, Development, and Technology (RD&T). To provide insight into how the Human Factors Division sets priorities for selecting projects and managing its research pro- gram areas, the human factors subcommittee asked the Federal Railroad Administration (FRA) to provide data on train derailments and other inci- dents and their causes and then to explain if and how the data are used for programming the Human Factors Division’s portfolio. The subcommittee

38 REVIEW OF FRA’S R&D PROGRAM then examined the extent to which project selections and program em- phasis areas appear to align with what the incident data suggest are the most significant safety concerns pertaining to human performance. The subcommittee then considered how other methods and criteria are used for setting priorities, including engaging with FRA’s Office of Railroad Safety (RRS), academia, and the railroad industry. Several individuals from other FRA units, academia, and industry who are familiar with human factors issues and the work of the division were also consulted to obtain additional views on the quality, relevance, dissemination, and communication of the division’s work. Rather than select individual projects to examine, the sub- committee focused on two of the division’s largest ongoing investments in a human factors laboratory and a safety institute. The chapter concludes with several observations and recommendations. ROLE OF INCIDENT DATA IN THE IDENTIFICATION OF RESEARCH NEEDS The human factors subcommittee reviewed FRA data on train derailments by reported cause, focusing on those in which human factors were reported to be the major cause. It also examined a second set of data on railroad fatalities, noting the dominance of grade-crossing, suicide, and trespasser incidents in these cases. There is, of course, a major distinction to be made among these two sets of incidents. Train derailments owing to human factors and environmental interactions tend to pertain to the performance of rail- road personnel, whereas grade-crossing and trespasser incidents stem mostly from the actions of people not affiliated with the railroad and who are usu- ally the victims. In all cases, however, the consequences can be traced to the behaviors, choices, and actions of people, and therefore research into means to prevent such incidents must have a strong human factors dimension. Derailment Causes Related to Human Factors Table 3-1 shows the number of derailments resulting from human factors– related causes from 2015 to 2019. From year to year, this figure fluctuated slightly from a little more than 400 incidents to nearly 500 incidents per year—totaling some 2,250 incidents over the 5-year period. As discussed in Chapter 2, an average of 1,300 derailments were reported to FRA annually during the period (see Appendix A, Figure A-1). Human factors, therefore, are a reported cause of more than one-third of derailments. Taking a closer look at these causal data, the five main human factors– linked causes for derailments during this period were improperly aligned switches (19 percent of incidents), shoving (or pushing) movements when a human was not present at the lead of the train or cut of cars (8 percent),

HUMAN FACTORS 39 shoving movements when the human at the lead of the train or cut of cars failed to maintain control (8 percent), movements through a switch that had been previously run through (7 percent), and failure to comply with restricted speeds (7 percent). These five derailment causes—out of a total of 95 reportable human factors causes—accounted for about half of train derailments caused by human factors. When considering the contribution of human factors–caused derail- ments to total reportable damage from all derailments, they accounted for slightly less than 30 percent of the total during the 5-year period. As shown in Figure 3-1, the following six causes were responsible for more than 40 percent of the reportable damage from human factors–related derailments: improperly lined switches, trains exceeding the speed outside yard limits, excess buff or slack action affecting train handling, uncontrolled or insuf- ficiently controlled shoving movements, and a catch-all category “other train operation/human factors.” Worker fatigue—from shift work, night work, and irregular sched- ules—has long been considered to be an important factor in many of the most prevalent and consequential human performance–related causes of derailments, such as excess operating speeds and switch run-throughs. FRA’s fatigue research program dates back to the early 1990s and continues to be an area of emphasis today. Table 3A-1 in the annex to this chapter shows the 11 active research projects in the Human Factors Division during 2019. At least four of these projects address fatigue, including studies on the impact of commuting on fatigue for maintenance workers and locomo- tive and monitoring engineers. Another project involves the development of a website intended to inform railroad personnel about the importance of getting adequate rest, the Railroaders’ Guide to Healthy Sleep (Federal Railroad Administration n.d.a). Other projects in the Human Factors Division’s portfolio seek to ad- dress a broad array of derailments and other incidents associated with human performance through investigations of automated systems and technologies and studies of how advanced technological systems in rail- roading can affect employee training, job design, and other personnel issues. By way of example, one project is examining how artificial intel- ligence (AI) systems can compensate for the loss of operator situational awareness by automatically detecting and reporting on the state of railway TABLE 3-1 Derailments Having Human Factors–Related Causes Reported to FRA, 2015–2019 2015 2016 2017 2018 2019 Derailments 473 413 427 464 473 SOURCE: Federal Railroad Administration n.d.b.

40 REVIEW OF FRA’S R&D PROGRAM signs, signals, and other objects in the path of locomotives. Another project has been investigating a new type of heads-up display that will result in improved engineer/conductor situational awareness of critical events and automation transitions. To provide a human factors laboratory for much of this work, the Hu- man Factors Division established and funds the Cab Technology Integration Laboratory (CTIL) at the U.S. Department of Transportation’s (U.S. DOT’s) Volpe National Transportation Systems Center. CTIL is a high-fidelity, full- sized locomotive simulator that serves as a tool for researchers engaged in studies of operator capabilities and performance. To enable the use of CTIL for large projects, the division has been dividing projects into phases, much like the approach used by FRA’s other research divisions. Phasing in this manner allows funding to be spread across multiple budget cycles and can provide a checkpoint mechanism to review project progress and modify the research approach if necessary. The 2015 Transportation Research Board (TRB) review of FRA’s R&D program noted that CTIL had been underused and recommended strategic FIGURE 3-1 Human factors–caused derailments from 2015 to 2019 that resulted in damage valued at $18 million or greater and were reported to FRA in millions of dollars. NOTE: Inset shows all 95 incident causes and how the top 6 account for more than 40 percent of all reported damages. SOURCE: Federal Railroad Administration 2020b. $70 $60 $50 $40 $30 $20 $10 $0 $70 $60 $50 $40 $30 $20 $10 $0 100% 80% 60% 40% 20% 0% Switch improperly lined Other train operation/ human factors Train outside yard limits, excess speed Buffing/ slack action, excess train handling Shoving movement, absence of person Shoving movement, failure to control

HUMAN FACTORS 41 planning to ensure more effective use of this resource, particularly by communicating its utility to industry to attract more industry interest and collaboration. FRA recently issued a strategic plan that emphasizes the creation of a CTIL research agenda that is informed by an understanding of industry needs and that emphasizes more active communications and marketing with industry. Fatalities from Suicide, Trespassing, and Grade-Crossing Incidents Between 2015 and 2019, 5,412 fatalities were reported to FRA from all railroad incidents. Table 3-2 shows the source of these fatalities, the vast majority of which stemmed from trespassing, suicide, and grade-crossing in- cidents. In nearly all years, trespassers accounted for about 40 to 50 percent of fatalities. Fatalities from grade-crossing incidents fluctuate over the pe- riod, but with a slight increase, while suicide fatalities have been declining, with what appears to be a potentially significant decline during 2019. This apparent decline may be attributable, at least in part, to the time it takes railroads and medical examiners to classify grade-crossing and trespasser fatalities as suicides. Grade-crossing and trespassing incidents together ac- counted for about 80 percent of fatalities in 2019, with some portion of these incidents likely to be reclassified later as suicides. Of these three major sources of railroad fatalities, suicide prevention currently receives the most attention in the Human Factors Division’s re- search portfolio. In particular, the division supports work by the Volpe Cen- ter to identify, implement, and evaluate suicide prevention countermeasures employed by railroads (Volpe National Transportation Systems Center 2017). The work includes using geographic information system mapping technologies to identify locations of trespass “hotspots,” understanding the causes of suicides along the right-of-way, investigating whether media TABLE 3-2 Railroad Fatalities Reported to FRA by Incident Type, 2015–2019 Fatal Incident Type 2015 2016 2017 2018 2019 Grade crossing 237 255 271 260 293 Trespassing 450 467 505 521 578 Suicide 328 274 277 280 206 Other 62 38 42 37 31 Total 1,077 1,034 1,095 1,098 1,108 NOTE: Data for 2018 and 2019 will change contingent on medical examiners’ determinations of whether a trespassing or grade-crossing fatality was a suicide. SOURCE: Federal Railroad Administration 2020a,c.

42 REVIEW OF FRA’S R&D PROGRAM coverage encourages suicide attempts, and cooperating with railroads and public agencies to disseminate information on the effectiveness of potential countermeasures. The subcommittee was informed that FRA RD&T funding for grade- crossing and trespasser research is programmed and administered by the Train Control and Communications Division, including projects to ensure safe interaction of road vehicles with trains at grade crossings and the use of AI and machine learning for identifying risky trespasser behavior around railroad tracks and crossings. Given the human dimensions to these issues, the subcommittee was surprised to learn that research in these areas was not programmed with more involvement by the Human Factors Division. OTHER CONSIDERATIONS WHEN PROGRAMMING RESEARCH Like the other divisions of RD&T, the Human Factors Division’s leader- ship and staff explained that other considerations go into the programming of the division’s research, including U.S. DOT strategic goals, legislative mandates, and needs identified by RRS and industry. A notable example is the division’s engagement with industry that led to the creation of the Short Line Safety Institute (SLSI). Spurred by the 2013 tank car unit train disaster in Lac-Mégantic, Quebec, that involved a small railroad, the divi- sion began discussions with the American Short Line and Regional Rail- road Association (ASLRRA) on the need to improve the safety culture of smaller (Class 2 and 3) freight railroads. These discussions led to a pilot project with ASLRRA, the University of Connecticut, and the Volpe Center to identify ways to measure the safety culture of short line railroads. As a result of this pilot study, and subsequent congressional interest and support, SLSI was created, which now accounts for about 40 percent of the Human Factors Division’s budget, as noted below. SLSI uses these funds in part to conduct voluntary safety culture assessments of small railroads using online employee surveys, onsite employee interviews, safety documents reviews, and field observations. The subcommittee also learned that the Human Factors Division is working with RRS to develop a program similar to the Federal Aviation Administration’s Aviation Safety Information Analysis and Sharing pro- gram, whereby regulators, airlines, trade associations, labor organizations, and suppliers share safety sensitive data for the purpose of mitigating safety problems. FRA’s plan is to develop and pilot a similar program for the railroad industry—the Railroad Information Sharing Environment (RISE)—which builds on FRA’s existing Confidential Close Call Reporting System and will require extensive collaboration with the railroad industry. If RISE can be successfully implemented, the division expects it to become

HUMAN FACTORS 43 an important source of data for human factors research and to prompt more collaborative research with industry. In addition, it may be considered one pathway for reducing concerns in the railroad industry about joint ef- forts to improve safety outcomes alongside the research division within its regulatory agency without being penalized for being candid about potential precursors to serious incidents. PROGRAM BUDGET ALLOCATIONS As shown in Figure 3-2, the Human Factors Division’s budget has been stable over the past 5 years, totaling $5.5 million to $6 million per year, including $2 million to $2.5 million for the SLSI program. Budget break- downs are not available by the two main areas of research, preventing human factors–related derailments and preventing fatalities from suicides, trespassing, and grade-crossing incidents. The portfolio of recent and cur- rent projects in the annex, however, suggests that a large majority of the budget is spent on the former. FIGURE 3-2 FRA Human Factors Research Division budget by major program in millions of dollars. SOURCE: Federal Railroad Administration Office of Research, Development, and Technology 2019d. Millions 2.50 3.22 3.54 3.54 3.54 3.54 2.32 2.00 2.50 $0.0 $0.5 $1.0 $1.5 $2.0 $2.5 $3.0 $3.5 $4.0 2015 2016 2017 2018 2019 Human Factors Short Line Safety Institute 2.00

44 REVIEW OF FRA’S R&D PROGRAM EXTERNAL VIEWS ON RESEARCH RELEVANCE AND IMPACT To obtain insight on how others view the relevance, impact, and reach of the Human Factors Division’s work, the subcommittee consulted with re- searchers who had worked on projects funded by the division, a longtime FRA official from a regional office, and representatives from commuter railroads. The commentary was largely positive, as the work supported by the division was consistently described as high quality, relevant to industry needs, and likely to produce early safety benefits, particularly in the case of suicide and trespassing prevention. Some questioned whether the division’s funding levels are sufficient given the importance of human factors research and the cost of investigating automated systems and other technologies. Some also questioned whether the phasing of work into short-duration projects was desirable because it limits the ability of doctoral students, who need longer time commitments, to participate fully in the work. The involvement of such students was described as vital for building human factors research expertise for railroad applications because experience in the field assists in developing a workforce with critical new skills. The Human Factors Division’s research dissemination and outreach efforts were described as competent but still hindered by lags in FRA report review and publication processes. One individual noted that FRA needs to improve its means of notifying industry and other stakeholders in a timely fashion when a research project is complete and the results are available. In particular, FRA’s eLibrary was described as being difficult to use to retrieve project reports, prone to technical difficulties, and not always up to date. Several commented that the division’s outreach would benefit from greater publicity of pilot test results, expanded use of digital means of communications such as periodic e-newsletters and webinars, and organization of regular dialogue sessions during industry confer- ences such as those of the American Public Transportation Association. In one conversation, the subcommittee learned that a senior employee of a commuter rail line was unaware of the Human Factors Division or other RD&T divisions and how their research products and services might have benefitted the passenger service. It was pointed out that the implications of the division’s work on topics such as suicide and tres- passer prevention extend to all railroads and even to the highway sector; therefore, the division should seek out more collaboration opportunities with the Federal Transit Administration (FTA) and the Federal Highway Administration (FHWA), which has closer ties to public agencies that op- erate heavy- and light-rail systems and state transportation departments that own and operate highways.

HUMAN FACTORS 45 OBSERVATIONS Trespassing and Suicide Countermeasures Program Holds Promise All indications are that the Human Factors Division’s ongoing programs to identify, implement, and evaluate trespassing and suicide prevention countermeasures are coordinated effectively through partnerships with and implementations by railroads. Inasmuch as trespassing and suicide preven- tion are major concerns for operators of transit rail and highway systems, opportunities may exist for wider application of this knowledge through in- creased coordination with FTA, FHWA, the public transportation industry, and state transportation departments, as well as with the Train Control and Communications Division, which programs research related to this topic. CTIL’s Strategic Planning Promises More Industry Application and Collaboration The 2015 TRB review raised concerns that CTIL was being underutilized, especially by industry. The Human Factors Division has since developed its strategic plan for CTIL and placed greater emphasis on industry consulta- tion, collaboration, and communications, which includes holding CTIL stakeholder meetings with industry partners. If implementation continues as planned, this emphasis can help ensure that this world-class human factors laboratory is used to the maximum extent to manage the many ongoing, and in some cases growing, needs to address safety issues such as worker fatigue, the effective application of automation, and improvements in hu- man–technology interfaces and integration. Phasing Research into Small Projects Has Pros and Cons The Human Factors Division seeks to maximize the use of funds for re- search output by staging research projects in phases. One of the advantages of this approach is that it allows funding to be spread across multiple budget cycles and can provide a checkpoint mechanism to monitor project progress and modify research plans as necessary. A disadvantage is that shorter duration projects may not sustain the development of budding hu- man factors researchers, such as doctoral students, whose involvement in projects is needed to build the talent pool for railroad applications. The committee was impressed with the technical knowledge and capability of the division’s staff. However, the accumulation and retention of domain knowledge and expertise outside the agency is essential for a research man- agement agency that is dependent on the expertise of contractors.

46 REVIEW OF FRA’S R&D PROGRAM SLSI Is a Success Story With a relatively small budget (about $2.5 million per year) provided by the Human Factors Division, the SLSI has provided a needed focus on improv- ing the organizational safety culture of smaller freight railroads. The project illustrates how FRA’s collaborations with industry can lead to cooperative solutions to problems and generate support for implementation across the industry. Because there are hundreds of small railroads across the United States, continued funding of SLSI and its safety culture assessments and interventions holds the potential for much wider reach and impact. Opportunities Remain for Increased Communication and Dissemination of Research Results The importance of the work conducted by the Human Factors Division does not appear to be matched by its capability to communicate and disseminate the results. Greater use of communication means such as e- newsletters, webinars, presentations, and workshops in conjunction with major industry conferences and technical events would seem to be war- ranted to ensure that the products of the division’s human factors research are known and available to potential users. The wide applicability of much of the division’s work in areas such as automation and trespassing and suicide prevention suggests a broader audience may be tapped, including the U.S. rail transit and highway sectors. RECOMMENDATIONS Understanding of human factors is important when considering nearly all causes of railroad safety problems and their possible solutions, from the design of safety devices on tank cars and other rolling stock to the devel- opment of automated track inspection technologies and train control and communications systems. Insight and knowledge gained from human fac- tors work in the railroad domain can also have broader application to other domains and vice versa. The work and expertise of the Human Factors Division is highly valuable and should be strengthened further and more fully exploited through collaborations with other divisions of RD&T and other modal administrations of U.S. DOT, as well as other agencies that conduct research into human factors such as the Occupational Safety and Health Administration in the U.S. Department of Labor, the Human Fac- tors Program in the Office of Safety and Mission Assurance at the National Aeronautics and Space Administration, and the U.S. Department of De- fense Human Factors Engineering Technical Advisory Group. For instance, the division’s work that promotes a strong organizational safety culture,

HUMAN FACTORS 47 investigates the integration of humans and automated systems, and seeks reductions in trespassing, grade-crossing, and suicide incidents is likely to be of keen interest to FTA and FHWA, both of which oversee transporta- tion modes that have these same needs and interests. With this goal in mind of expanding the reach and influence of the Human Factors Division, the subcommittee, in concurrence with the full study committee, recommends that RD&T ensure that the Human Factors Division • Becomes more involved in the design, development, and program- ming of research projects across FRA’s RD&T portfolio; and • Engages more frequently with other U.S. DOT modal administra- tions and other relevant federal agencies to identify opportunities for its work to inform, and be informed by, their human fac- tors–related challenges and research, and to collaborate on the design and conduct of relevant research and the dissemination of those research results and products that have broad, multi-modal application.

48 REVIEW OF FRA’S R&D PROGRAM ANNEX TABLE 3A-1 Human Factors Division Projects, 2019 Human Factors Division Project Title Funding Project Duration The Impact of Commute Times on the Fatigue and Safety of Locomotive Engineers $180,000 May 2018–December 2020 New Jersey Transit Run- Through Switch Project $200,000 October 2016–June 2019 Railroaders’ Guide to Healthy Sleep Website www.railroadersleep.org $600,000 April 2015–March 2020 Maintenance-of-Way (MOW) Worker Fatigue $150,000 May 2016–June 2019 Head-Up Display (HUD) Alternative for Locomotives $150,000 June 2016–June 2019 External Perception for Locomotives (ExPL) $156,000 (PI) $161,000 (PII) $120,000 (PIII) April 2018–April 2019 Monitoring Engineer Fatigue (MEFA) $100,567 (PI) $179,580 (PII) $114,471 (PIII) September 2018–September 2019 Design of a Robust Locomotive Operating Mode GE 20% cost share $489,304 $500,908 October 2018–September 2020 MIT Augmented Reality Head-Up Display (HUD) $500,000 $500,000 September 2018–September 2020 Human Error Potential in Human-Automation Interaction $397,276 September 2018–December 2019 Suicide Countermeasures $160,000 October 2018–September 2019 Short Line Safety Institute (SLSI) $2.4 million $100,000 to Volpe October 2017–September 2018 October 2018–September 2019 NOTES: Funding level is for FY 2019 unless otherwise specified. GE = General Electric; MIT = Massachusetts Institute of Technology. SOURCE: Federal Railroad Administration Office of Research, Development, and Technol- ogy 2019a.