Human and Organisational Factors in Railways: …...HOF in GB Railway 14th November ERA Train crew...

Human and Organisational Factors in Railways: What Keeps Us Awake at Night?

Paul Leach

HOF in GB Railway 14th November ERA

Britain’s railways

• 21,000 miles (about 33,600km) of track

• 10,000 route miles (16,000km)

• 2,500 stations

• 4,000 trains

• 20,000 services run every weekday

• 216,000 employees

• 17,000 signals, 6,300 level crossings

• 600 tunnels, 2,000 viaducts

• 15,000 overbridges, 20,000 underbridges


Britain’s railways

• 1.71 billion passenger journeys made

• 86million tonnes of freight lifted

• Rail industry contributes over £10billion in gross value added to UK economy

• £12.9billion in time saved

• 7.7 million tonnes of CO2 saved


Britain’s rail industry

Human and Organisational Factors


Technical & non-technical skills, well-being, fatigue

Safety culture, leadership, managers, change

Equipment, workload, systems & procedures

HOF in GB Railway 14th November ERA8

Recent impacts of Human & Organisational Factors


Drivers

• SPAD increase over the summer

• Range of factors affect SPAD rates at this time of year, including higher temperatures, fatigue and longer sunlight hours

• Gradually rising trend in the proportion of signals that are approached at red and in the probability of passing a signal at danger (per signal approach)

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Trackside

• 25th Feb 2018 - a length of rail left foul of the line being struck by a train

• 21 February 2018 - two track workers moved clear of a Tyne and Wear Metro train two seconds before the train passed them at around 65km/h

• 10 July 2018 – a train entering what was thought to be a protected portion of line at Dundee, resulting in track workers flattening themselves against a bridge parapet before it passed

• Analysis of these and other incidents revealed that during setting up, maintaining and handing back of protection, 14 key task steps rely solely on human performance to prevent a serious accident.

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Train crew and passengers

• Notting Hill Gate station, 31 January 2018 – passenger dragged along platform and into tunnel

• Bushy station, 26 March 2018 - passenger dragged along the platform

• Greater Manchester, 30 May 2018 - passenger trapped in tram doors and dragged

• Combination of factors:

• Door design and obstacle detection

• Passenger behaviour

• Train crew visual checks

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Current areas of work in Human & Organisational Factors


What is ‘Cognitive Underload’?

▪Mental workload too low

▪ Performance effects:

– Decreased performance on vigilance tasks.

– Increased reaction times.

– An increase in the number of performance errors.

– An increased chance of failing to respond to environmental stimuli.

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The problem in the rail industry

▪ Long periods of time with little cognitive effort

▪ Train cabs have few visual and auditory distractions

▪ Improvements of in-cab environments

▪ Smoother journeys

▪ Infrequent physical actions or insufficient stimulation

– Lack of alertness and engagement

▪Developments in automation

– Automatic Train Operation (ATO)

– ERTMS

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Driver workshop findings

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Critical factors in making decisions

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Supportive/competent colleagues

Clearly-defined authority

Decision-support tool

Experience

Confidence

Training

Rule book Supportive manager

Time pressure

Company culture


What is a decision-support tool?

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• Designed to be a simple, easy-to follow decision-making tool.

• Structures the decision-making process, does not make the decision.

• Generic to a wide range of situations.

• Guides user through the process of making a decision, avoiding shortcuts and taking into account information available at the time.

• Can be used in situations where there is no rule or procedure that mandates the actions to take, or where it is not possible to seek authority in a realistic time frame.

• Record of using decision-support tool can be used afterwards as evidence of thought processes involved at the time.

• Not a checklist or flowchart to guide through a specific task.


Decision support tools – emergency services

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• Joint Emergency Services Interoperability Protocol (JESIP) – Joint Decision Model


Fatigue

• In our industry fatigue is a factor in 20% of high risk incidents

• The effects of serious fatigue are comparable to being over the drink driving limit: poor judgements, slow reactions, poor memory, impaired vision.

• https://www.rssb.co.uk/Pages/fatigue-and-alertness.aspx

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https://www.rssb.co.uk/Pages/fatigue-and-alertness.aspx


Respect the edge

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• Passenger safety campaign, to replace Lend a Helping Hand

• Focuses on different groups of passengers using different imagery

• Videos and artwork for use on digital media –websites, social media pages, digital billboards – and for use as posters

• New campaign will launch on 3rd September focusing on the families and parents with children theme, as we see the new school year begin.

• https://www.rssb.co.uk/pages/respect-the-edge-campaign-assets.aspx

https://www.rssb.co.uk/pages/respect-the-edge-campaign-assets.aspx


Culture and leadership

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Accident Investigation Training Development

Revised RIS-3119 Rail Industry Standard for Accident and Incident Investigation to be published in September 2018 – includes consideration of Human and Organisational Factors

Member consultation indicates a strong demand for training support to build competence in investigators and improve investigation quality

Phase 1 - Training Needs Analysis:

• Interviews & workshop held to identify essential training elements

• Training spec and proposed course structure to be delivered October 2018

Phase 2 - Training Development (pending approval):

• Work will begin in November 2018 to develop training package for accident investigators, for delivery next year

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1.1 Attention to detail

1.2 Overall awareness

1.3 Maintain concentration

1.4 Retain information

1.5 Anticipation of risk

1. Situational awareness

2.1 Systematic & thorough approach

2.2 Checking

2.3 Positive attitude towards rules & procedures

2. Conscientiousness

3.1 Listening (people not stimuli)

3.2 Clarity

3.3 Assertiveness

3.4 Sharing information

3. Communication

4.1 Effective decisions

4.2 Timely decisions

4.3 Diagnosing and solving problems

4. Decision making and action

5.1 Considering others’ needs

5.2 Supporting others

5.3 Treating others with respect

5.4 Dealing with conflict / aggressive behaviour

5. Cooperation and working with others

6.1 Multi-tasking and selective attention

6.2 Prioritising

6.3 Calm under pressure

6. Workload management

7.1 Motivation

7.2 Confidence and initiative

7.3 Maintain and develop skills and knowledge

7.4 Prepared and organised

7. Self-management

NTS CategoryKey: NTS Skill

02A. What makes a good member of safety-critical staff? 1 of 5

Non-Technical Skills

Personal Protection Strategies


Personal protection strategies

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• I adapted a technique (such as short journey concept) to assist me in controlling distractions and remaining mindful and alert

• I scan what's happening and verbalise if I identify a change and/or risk emerge.

• I organise my checking process so they flow easily, e.g. one check flows into the other so that it makes sense to me and I can follow a pattern that I can remember

• I use commentary signalling

• I change seating position when there is cautionary signal

• I use brown reminders, and my colleague has created reminders to put on controls

• I draw a virtual line along the platform and the train to help me scan for passengers and that the doors are closed


Personal protection strategies

• The more unusual examples:

• Singing/talking

• Speaking aloud in a different voice

• Elastic band on wrist

• Spray water mist on face using atomiser

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Conclusions

• We have a safer network but still significant risks to workers and passengers

• We have broken HOF into 10 areas

• Carrying out work in a number of these areas – underload, leadership, decision making

• Trying to incorporate the 10 areas and HOF more generally into national standards for accident and incident investigation

• Continuing to try and raise passenger awareness of the risks associated with rail travel and the simple behaviours they can exhibit to keep safe

• Looking to encourage staff to take responsibility for their own safety through personal protection strategies

• Its an on-going work in progress!

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Questions

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Human and Organisational Factors in Railways: …...HOF in GB Railway 14th November ERA Train crew...

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