Worker was exposed to the hazard of being struck by a moving railcar on a terminal.


Stacking containers on a string of railcars.

Activity at time of incident:

A longshore worker was placing locking cones into container corners prior to a top loader setting a second container on top of the existing container in a line of "double stacked" railcars in the yard.

Incident Description


In this On-Dock-Rail operation, a longshore worker was placing locking cones on the top four corners of each lower container on a rail gondola car. A top loader would then stow a second container on the railcar. The worker would then lock the cones and move to the next railcar. The rail crew was working on Track 4 and the adjacent Track 3 was inactive. Electrical power was energized throughout the yard and engines were working a nearby facility, but the worker and rail crew did not anticipate any railcar movement on Tracks 3 or 4.


While working on Track 4, a worker ran out of locking cones. He climbed on top of the adjacent string of railcars on Track 3 to get additional locking cones to continue his work on Track 4. Unknown to the worker and rail crew, a switch had been incorrectly thrown which caused the locomotive engine to proceed down Track 3. As the worker was gathering the cones from a railcar on Track 3, the railcars were struck by the incorrectly routed engine. The worker was knocked down between two railcars and he was run over and killed.

Relevant Factors:
  • There was a lack of communication between the terminal, operation supervisors, and workers.
  • There were no signs or signals to warn workers of possible movement of railcars within the yard.
  • There were no mechanical means of preventing railcar movement on certain tracks.

Applicable Standards and Control Measures

  • 29 CFR 1917.17(d): Railcars shall be chocked or otherwise prevented from moving.

Other Relevant Standards and/or Control Measures

These hazards could have been prevented if the driver:

  • Ensuring that the supervisor communicates with the driver and provides confirmation to enter the terminal (before a train enters a terminal facility).
  • Ensuring that supervisors communicate to workers that rail movements were taking place in the yard and making sure that the operation and safety instructions were confirmed.
  • Providing suitable warning signs or other protective means to protect workers from stepping in front of moving railcars or trains.
  • Ensuring that supervisors give safety talks at the beginning of each shift. Topics should have included: layout of yard, projected rail activity, and individual responsibilities.
  • Locking out switches to ensure that locomotives would follow the intended track routing.

This type of incident was the basis for locking out switches.