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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 recommendationsA 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
WiderOrganisational
Culture
barriers barriers barriers
INCIDENT INVESTIGATION IN THE RAIL INDUSTRY
Senior Management Overseeing
IMPLEMENTATION
INVESTIGATION
RESEARCH
Dr George CharalambousHuman 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
