Post on 02-Jan-2016
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1Deutsche Bahn AG, Fritz Schröder, Safety VS
16th International Railway Safety Conference
The human factor
Dublin Castle, Tuesday 24th October
Deutsche Bahn AG
Fritz Schröder
Safety VS
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Causes
Causes of irregularities in rail operations of Deutschen Bahn AG
90%human failings
10%other causes
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Railway Safety Directive
Safety Management System
Safety Program 2003: safety targets and plans on how to achieve targets
1. Level crossings2. Human Factors3. Platforms...
Project ‘Investigation of railway-specific human error’
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Human actions in complex systems
the ‘blunt’ end (removed from the incident in terms of space and time), where it is the accompanying circumstances of an accident that will tend to be described
‘pointed’ end, where the direct precipitating causes of the accident will be identified
Factors that have an effect on performance
Organisational environment Organisation
GroupsTechnology
Humanbeings
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Barrier 1
Barrier x
Path of a potential accident
Jim Reason’s model of the way an accident arises (1998)– the ‘Swiss cheese’ model
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STOP
Barrier 1
Barrier 2
Barrier 3
Barrier x
Incidentoccurs
STOP
Path of a potential accident
Jim Reason’s model of the way an accident arises (1998)– the ‘Swiss cheese’ model
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Organizational learning
In-depth analysis on all levels of the system
Change of organizational factors
Single-loop learning:Local, short-term changes related to the specific event
Double-loop learning:Extensive long-term learning & improvement beyond specific event
Safety-related event
Argyris & Schön, 1996; MTO, 2003
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Organizational environmentOrganizationGroup levelTechnicalHuman
Two views of human error
1. Human error = cause End of investigation What?
2. Human error = symptom Start of investigation Why?
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Safety Culture
safety as a priority rulebook conservative decisions reporting culture rejection of any actions and conditions that are unsafe learning organisation
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Programme for DB Group executives at the highest level
Further development of safety culture and risk management awareness
Information and discussion about trends and developments in European and national safety requirements
Raising consciousness of the importance of safety in the rail system network
Dealing with the conflict of goals between safety, quality and economic considerations
Aims