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There is resistance among railway companies and their occupational health services to rehabilitating locomotive engineers with ischaemic heart disease to their former driving work.To study the outcome of vocational rehabilitation for locomotive engineers with ischaemic heart disease.In seven European countries, selected locomotive engineers with ischaemic heart disease were compared to a matched group of healthy engineers. At the end of each calendar year between 1990 and 1999, questionnaires were completed by local occupational health physicians to provide information on accidents, incidents (professional mistakes), sick leave, (recurrent) cardiac events, death and early retirement. We used the life table method with five follow-up years to calculate the risk of accidents, incidents and recurrent cardiac events.The accident rate for the cardiac group was 3.8 accidents per 100 person-years, as compared to a rate of 6.0 in the reference group. The rates for incidents were 0.9 and 2.0, respectively. Neither of these differences were statistically significant. The duration of sick leave was significantly longer among the cardiac group than it was among the reference group, but only in the first follow-up year. Thirteen recurrent cardiac events occurred in the cardiac group, as compared to a single cardiac event in the reference group. There was no difference in the proportion of retirement cases. One engineer in each of the two groups died of cardiac disease.Locomotive engineers can safely resume driving duties following onset of cardiac disease.