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Audit Reports


FRA Lacks Written Procedures and Formal Planning for Oversight of Railroad Hours of Service Compliance and the Passenger Railroad Fatigue Management Requirements

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What We Looked At
The Federal Railroad Administration’s (FRA) recent data show that human factors, which include fatigue, remain the leading cause of reportable non-grade crossing train accidents. In particular, the rate of human factor-caused train accidents reached a 14-year high of 1.43 per million train miles in 2022. According to FRA, overseeing railroad fatigue management and compliance with Federal Hours of Service (HOS) requirements is part of the Agency’s ongoing efforts to address the adverse impacts and underlying causes of fatigue in the railroad industry. Given these factors, we assessed FRA’s (1) oversight of HOS compliance, (2) pursuit of civil penalties for HOS violations, and (3) oversight of passenger railroad compliance with fatigue management requirements. 

What We Found 
Three FRA staff in two divisions—the HOS subject matter expert (SME) and two fatigue SMEs—oversee HOS compliance and fatigue management for the entire railroad industry. However, the oversight processes and analyses are not fully documented and there is no evidence of risk-based planning. Specifically, there are no detailed procedures documenting how FRA’s staff plan or perform oversight of HOS compliance or required analyses of passenger railroad work schedules and fatigue mitigation plans. FRA also lacks guidance for many HOS violation penalty amounts as well as procedures for producing accurate Annual Enforcement Reports. As a result, FRA does not have the procedures and accurate data necessary to effectively target its limited resources to the highest risk areas or adequately oversee different railroad types. 

Our Recommendations 
FRA concurred with all 19 of our recommendations to improve its oversight of HOS and fatigue management and provided appropriate actions and completion dates. We consider these recommendations resolved but open, pending completion of planned actions.


No. 1 to FRA
Finalize and implement the draft HOS complaints SOP to provide details on the HOS SME’s evaluation, investigation procedures, and tracking.
No. 2 to FRA
Develop, document, and implement a process to routinely analyze HOS complaint data to identify trends and communicate results to enforcement staff.
No. 3 to FRA
Develop, document, and implement a process for analyzing excess service reports, identifying trends, and communicating results to enforcement staff.
No. 4 to FRA
Improve how excess service reports are submitted by railroads or processed by FRA to facilitate data collection and analysis.
No. 5 to FRA
Formally document the HOS audit process, including factors to consider when selecting railroads for audit (such as complaints, excess reports, and/or other factors), in a compliance manual or SOP.
No. 6 to FRA
Develop and implement centralized storage for key HOS audit documents, such as executive summaries, inspection reports, or other pertinent correspondence.
No. 7 to FRA
Evaluate inspector and SME staffing needs based on data to effectively perform HOS oversight, including audits, and document the results.
No. 8 to FRA
Update the OP Compliance Manual, the Signal Compliance Programs and Policies, and/or General Manual to clarify the definitions of HOS-related activity codes for OP and S&TC disciplines so that inspectors can accurately record activities that do not result in findings of noncompliance and include specific guidance to inspectors completing HOS-related inspection reports, including the correct use of source codes for specific HOS activities, and when multiple same-day HOS reports should be created.
No. 9 to FRA
Modify the Railroad Inspection System for Personal Computers (RISPC) to only accept correct HOS-related inspection report entries and add activity codes to record defects and violations of 49 C.F.R. § 228.407.
No. 10 to FRA
Develop and implement training for OP and S&TC Division specialists and inspectors on reporting HOS-related inspections correctly, including the mandatory use of activity code 228 in conjunction with either HSL or 228P, and the meaning of those activity codes.
No. 11 to FRA
Develop, document, and implement a review process that includes the HOS SME to check the accuracy of HOS-related inspection reports.
No. 12 to FRA
Document and implement HOS oversight planning processes, including guidance on data sources that should be used to inform planning.
Closed on
No. 13 to FRA
Review and clarify FRA’s Civil Penalties Schedule to include all sections of 49 U.S.C. Chapter 211 and 49 C.F.R. Part 228 Subparts D and F in the published violation base amounts for HOS civil penalties.
No. 14 to FRA
Correct the RCS error that results in incorrect case-level violation counts.
No. 15 to FRA
Document the current RCS configuration that shows formulas for calculations performed by the system and data sources.
No. 16 to FRA
Formalize existing RCC enforcement process guidance in a standard operating procedure, memo, or manual and provide training for users of RCS, including data quality steps.
No. 17 to FRA
Develop, document, and implement guidance on producing Annual Enforcement Reports, including parameters for what information is included or updated, and validating the accuracy of reported data.
No. 18 to FRA
Finalize the process document for conducting a baseline review of all passenger railroads subject to 49 C.F.R. § 228.407 and complete the baseline review.
No. 19 to FRA
Finalize and implement the draft SOP for oversight of 49 C.F.R. § 228.407.