1. Initial response
- Photos
- Measurements
- Degraded operations
Hard data collection
- System logs
- Technical experts
Soft data collection
- Witness statements
- Interviews
Review
existing local
operating
procedures
Compare
against
standards:
- ROGS
- RSSB
Developement of recommendations
A stakeholder owning each recommendation
Management
Implementation Plan
- Clear end date
- Transparent progress
Workshop with stakeholders Why did they do what they did?Why there was a deviation?
Establish the “WHY”
- Lack of response
- Lack of competency
to respond
- No investigation checklist
- Distortion of evidence
- Not willing to provide
statements
- Blame culture
“Holes” in
Organisational
Procedures
Lack of Training
& Competency
Poor Fatigue
Management
Wider
Organisational
Culture
barriers barriers barriers
INCIDENT INVESTIGATION IN THE RAIL INDUSTRY
Senior Management
Overseeing
IMPLEMENTATION
INVESTIGATION
RESEARCH
Dr George Charalambous
Human Factors Consultant
Benefits of using our Human Factors team:
- Understanding human performance and develop optimization strategies
- Reduction in design risk
- Increase user acceptance
- Access to a wide range of Interfleet’s internal rail expertise covering:
rolling stock, infrastructure and advanced rail control systems
TIME LINE OF EVENTS
Benefits of SMT
involvement
- Ownership of the plan
- Resource allocation
- Means for escalating issues
- Reinforce safety message
- Shift in organisational
culture
www.interfleetgroup.com
What has actually happened Vs. What should have happened
Review
existing local
operating
procedures
Examples