FROM THE ORGANISATIONAL ACCIDENT TO RESILIENCE, THROUGH HUMAN RELIABILITY MANAGEMENT AND JUST CULTURE -ACCIDENT OF SANTIAGO DE COMPOSTELA 2013, SPAIN-
Baltasar Gil
ESM Research Institute into Safety and Human Factors, Spain
From the Human Factors perspective, he has directed diverse research, seminars and workshops, published articles, books and manuals in the sphere of safety in industry and transport, and organized meetings on an international scale. His basic training stems from the fields of Safety, Ergonomics and Psychology geared towards accident prevention and risk control.As a specialist in Human Factors, he performs as a researcher for a considerable number of companies developing projects on assessment, training, and developing strategies to improve work conditions and risk control in the Industry, above all in Transport.He takes part in managing ESM INSTITUTE research projects in the fields of reliability and human factors.
Abstract
One of the most important European accidents regarding passenger railways occurred on 24th July 2013 in Santiago de Compostela, Spain. All reports indicate human error as the most visible cause for the disaster but, as in all... [ view full abstract ]
One of the most important European accidents regarding passenger railways occurred on 24th July 2013 in Santiago de Compostela, Spain.
All reports indicate human error as the most visible cause for the disaster but, as in all complex accidents, underlying this proof are factors of differing natures, with the organisational factors giving rise to the situation of final operator vulnerability being of considerable importance.
The elements appearing in this incident for it to be labelled an Organisational Accident are justified.
This paper will consider the most relevant organisational factors in order to learn lessons which may be transferred to this sector. Particular emphasis will be placed on the need to correctly integrate all the elements making up human and ergonomic factors in the development of Safety Management Systems, together with the requirement to perform risk evaluations of human risk factors both when start up a new line and when confronting significant changes, while also putting forward preventive and protection measures finally leading to reasonable risk acceptance criteria Commission Implementing Regulation (EU) No 402/2013 of 30 April 2013 on the common safety method for risk evaluation and assessment and repealing Regulation (EC) No 352/2009 .
Finally, the concept of Just Culture is introduced as a necessary line of work to advance in the identification of risks with a human origin and the commitment of organisations to work on safety from non-punitive points of view.
The aim is to advance and mature as an organisation in order to establish
Organisation Resilience Management Systems as an advanced support the face of the threats to and the weaknesses of the railway sector that is constantly changing and growing.
Authors
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Pilar Calvo Holgado
(ESM Research Institute into Safety and Human Factors, Spain)
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Baltasar Gil
(ESM Research Institute into Safety and Human Factors, Spain)
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Antonio Castellano Colmenero
(ESM Research Institute into Safety and Human Factors, Spain)
Topic Areas
Accident and incident investigation , Human error and human reliability , Resilience engineering and rail system design trade-offs
Session
2PS-2C » Culture / Fatigue (11:50 - Tuesday, 15th September, Blossom)
