In case of emergency press button B … or is it C?.
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Transcript of In case of emergency press button B … or is it C?.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Let’s find the broken bits ..
Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.
Everyone wanted to work safely.
None of them did.
The entire system had drifted.Drifted into failure.
Traditional Two Way Radio Personal Communication Device
Formal Informal
Structured Spontaneous
Open Channel – everyone hears Closed Channel
Situation awareness for all Just the two of us
Independent check of accuracy Credibility
Monitored, recorded May not be monitored or recorded
Press to talk Find number, dial, wait to connect
Anyone can answer Presumption of correct connection
Static configuration Numbers change without notice
Incident Situation
Pakenham Train radio failed, cellular only medium.
Lavington Train radio no coverage, cellular only medium.
Waterfall Crew disabled. Passenger phoned 000.
Leigh Creek Sat and cellular damaged.
Guelph Cellular privacy used to cover error, created hazard.
Grawlin Plains Incident report by phone, numbers not given.
Asta Imminent collision, numbers not known
Knowledge and error flow from the same mental sources, only success can tell one from another.Ernst Mach, 1905
• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.
Recommendations for Success
• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.
Recommendations for Success
• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.
Recommendations for Success
• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.
Recommendations for Success
• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.
Recommendations for Success