What are the key HOF issues?
The immediate cause of signals passed at danger is often a lapse in concentration by a driver on approach to the signal. This can mean that the obvious focus for an investigation is on the actions (or inactions) of the driver involved, sometimes at the cost of more subtle but powerful influences being missed.
What did you do?
We are moving the focus of our investigations to not only examine the actions of the driver, but to also identify why the driver acted in that way and what the influences of the wider railway system design were on the event. Some of the key activities in doing this are a human factors interview with the driver following the event which focusses on learning outcomes for the individual and the organisation, updating our investigation proformas to incorporate more elements of the design of the system, and development of an Excel-based dashboard to track the factors involved in SPADs over time. We are also doing more structured statistical analysis of the types of signals where SPADs happen.
What were the results?
The wider approach to analysis has identified some factors, such as elements of the signalling design, which may increase the possibility of SPADs. Using these results, we can work with signalling engineers to update our standards and incorporate the learning into new signalling schemes.
Author: Nora Balfe, Irish Rail
