Good human factors in event investigation in the rail industry

Events in the railways, whether an incident, accident or a near-miss, happen and the consequences can be catastrophic. Although the railways have a long history of learning from events, integrating good human factors in event... [ view full abstract ]

Events in the railways, whether an incident, accident or a near-miss, happen and the consequences can be catastrophic. Although the railways have a long history of learning from events, integrating good human factors in event investigation is still priceless. The aim of a good human factors investigation is to identify, not only the immediate causes, but also the underlying human factors that set the scene for the event to take place. Lack of adopting this strategy, or even worse attributing blame, can undermine the organisations’ ability to learn, evolve and successfully implement safe systems of work. In this paper, the approach taken during rail incident investigations is described. A holistic view of the incidents is adopted by considering the engineering causes along with the human factors both at an organisational and at an individual level. Data are collected from the key stakeholders involved in the events across various levels within the organisation. Site visits are carried out to understand the working conditions. Furthermore, a review of the organisations’ procedures and operational records is undertaken against relevant industry standards. These steps enable the identification of the root causes in the chain of events. The output of this approach has profound implications on the way safe systems of work are implemented. It enables organisations to obtain a better understanding of the contributing factors, thus shifting the attention away from the individual, and look at the bigger picture. This can assist the improvement of the engineering systems as well as safety management systems, including competency assessment, training and fatigue management.