Tuesday 25 February 2014
Human Factors / International Event

Human Factors in investigation of accidents / incidents

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From 10 – 11 February 2014, the Safety Unit organised the international workshop on “Human Factors in Investigation of Accidents/Incidents”. On this occasion, Mr Wisniewski, Fundamental Values Director, welcomed the 56 participants from 25 UIC members, with the kind participation of the Belgian Railway Accident and Incident Investigation Body, EUROMED RRU, the University of Southern Denmark and DEDALE.
The first session of the workshop highlighted the human factors approach and safety management.

Professor Erik Hollnagel from the Institute of Regional Health Research, University of Southern Denmark delivered a presentation where he explained that safety has traditionally been understood as a state where the number of things that go wrong is as low as possible (Safety-I). From this perspective, the purpose of safety management is to keep the number of accidents and incidents as low as possible.

Safety management therefore starts from manifestations of the absence of safety and paradoxically measures the level of safety by counting the number of failures rather than the number of successes. This leads to a reactive approach of responding to what goes wrong or what has been identified as a risk. He added that focusing on what goes right rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. This leads to a proactive approach that sustains everyday acceptable performance, rather than one that prevents hazards from being realised.

Jean Pariès from DEDALE, explained that we have different visions of incident/accident analysis. Rather than finding “failures” and their causes and trying to fix them, we must seek what incidents teach us about the “safety model” and all its assumptions, and ask how we believe control is maintained. He insisted on the fact that if we want to have a reliable and robust control process, we must fix the safety model, not the causes, and define safety indicators significant of this robustness, rather than based on incident frequency.

Dr Anne Mills from RSSB presented the incident classification system developed in GB to collect and analyse human errors involved in their railway incidents. She said that Safety Management has become an integral part of business management in the rail industry with organisations realising that safety and efficiency are complimentary, NOT contradictory. In the GB rail industry they employ effective Safety Management processes identifying and analysing hazards and mitigating risk factors. Human Factors play an integral role in both Safety Management and incident/accident investigation.

Safety learning must include looking across events to identify trends and patterns and to look at trends across incidents we need to classify them. In Great Britain they use a database known as SMIS (“Safety Management Information System”). It is the industry’s national database for the recording of safety related events that occur on the UK rail network and is mandatory for all Infrastructure Managers and Railway Undertakings operating on Network Rail managed infrastructure.

Sian Evans, also from RSSB, explained that the AcciMap technique is a systems-based accident analysis method developed by Svedung and Rasmussen (2002) which is based on a risk management framework. It arranges the various causes of an accident into a tree diagram, with the accident sequence at the bottom and the causes branching upwards and helps to consider the failures of the front line staff and also the system-wide failures involved. AcciMap has been applied to a range of accidents in the oil and gas, maritime, rail and aviation industries.
The second session of the workshop was dedicated to concrete examples of accidents/incidents and to the human factors approach as it’s dealt by the railway operators.

L. Mathues, Chief investigator from the Belgian Railway Accident and Investigation Body, reported on the human and organisational factors analysis and the safety management system analysis of the collision of two passenger trains at Buizingen on 15 February 2010.

Adolfo Moreno and Felix Garcia (RENFE) presented the Human Factors and Human Error investigations and the summary of the 12 measures adopted in the wake of the Santiago accident implemented in the rail sector and directly linked to traffic safety and Human Factors.

Kentaro Kimura (West Japan Railway) gave a presentation about multi-faced analyses and risk assessment for safety railway operations based on the analyses of JR Fukuchiyama line train derailment accident. He said that a serious accident should be regarded as an “organisational accident”. All aspects of an accident should be analysed organisationally and systematically from various points of view, which are based on a scientific and theoretical basis. The objective is to construct a system toward proactive safety measures taking into account human factors.

Christian Neveu (SNCF) gave details about the analyses of the derailment of a regional express train on an incorrectly positioned turnout upon its arrival at the station of Aigues Mortes. He also presented two other practice cases related to two incidents in Marseille. He showed the post-incident action plan based on all the weaknesses identified in the system.

Petr Potapov (RZD) gave a presentation on an accident in the area of train movements. He explained the accident prevention plan with its four main points: organisational, information, technical and legal measures.
Anna Patacchini (RFI), Human Factors and accident investigation, state of play from the IM’s perspective. She informed participants of the background work on Human Factors in the Italian Railway System and illustrated this with analyses of an accident at a level crossing.

The workshop ended with a fruitful panel discussion led by Meryem Belhaj where participants asked many questions related to their every day work about safety, human factors, safety indicators, new technologies and human reliability, etc.
To close the meeting, Peter Gerhardt stressed the importance of the international cooperation which is essential to exchange best practice in order to find common solutions and continuously improve the railway system.

For further information please contact Meryem Belhaj, Senior Advisor for International Training and Human Factors: belhaj@uic.org

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