The complexity of railway accident investigations – a system in its own right

Railway occurrences in South Africa remain high, despite occurrence investigations conducted by the Regulator and railway operators. There is a need to understand how effective interventions are within the railway industry in... [ view full abstract ]

Railway occurrences in South Africa remain high, despite occurrence investigations conducted by the Regulator and railway operators. There is a need to understand how effective interventions are within the railway industry in addressing critical occurrences. A failure to thoroughly identify what really happened may be a possible reason for the number of recurrences. The primary aim of an investigation is to uncover the events at all levels of the system and to identify remedial actions to prevent a recurrence. If accidents are being investigated, why then do the number of occurrences remain largely unchanged? An objective of this research was to identify the inherent or systemic factors within the railway system that influences the effectiveness of the investigation process. Systemic factors refer to challenges, pressures, frustrations or obstacles that contribute to the complexity of railway accident investigations. Rasmussen’s (1997) Risk Management Framework was operationalised for the South African railway system. A qualitative multi-method approach was adopted in this research. Examples of methods included a print media analysis of reported railway accidents, governance document analyses, semi-structured interviews with railway investigators, observations during actual inquiries and analyses of railway occurrence reports. The data was compared and verified against each other using triangulation. Triangulation is beneficial as the verification of the data helps to improve the validity of the information, which is particularly important in qualitative research. The advantages of adopting qualitative research using a multi-method design provided the researcher with an in-depth understanding of the railway system and the intricacies within a “system of systems”. The results illustrated that systemic factors inherent within the system of accident investigations influences the effectiveness of the investigation process. Examples of systemic factors identified included: no National Rail Policy, limited resources to investigate, shortage of skilled investigators, absence of investigator training, non-compliance to governance documents, financial constraints, and a blame culture. The results were integrated and graphically illustrated in an Accimap, highlighting the complexity of accident investigations. It can be concluded that the system of accident investigations is indeed a complex system in its own right, and not just the accidents themselves. The complexity of the system of accident investigations is influenced by decisions makers and events from all levels of the rail socio-technical system, of which the system of accident investigations is nested within. System principles such as integration, feedback, demands, resources, constraints and flow of information were evident from the results in this research. The rail system in South Africa is an example of a disjointed system of systems where the performance of other systems, the context, conflicting goals and organisations’ commitment to safety contributes to the complexity of the investigation system. Deficiencies and complexities in the system of accident investigations limits the effectiveness of the entire investigation process from achieving its objectives, offering an explanation for why railway safety trends remain unchanged in South Africa. Recommendations for thorough, independent investigations and focussing on a systems approach are essential for improving railway safety in South Africa.

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