Accidents and incidents provide ample, although undesired opportunities to improve
understanding of system processes with the aim to improve control of risks that are inherent
in indented activities. Railway industry in Europe knows that accident review is important;
moreover, many of not most railway workers have high safety awareness. However, learning
from railway accidents by railway organisations is hardly organised despite all the effort over
the last 150 years that has gone into collection of accident and incident data. Recent studies
(also) within the context of SAMRAIL demonstrate that learning processes hardly exist, or
only by chance due to devoted individuals (Koornneef and Kingston, 2003). The privatisation
of formerly national railway companies also has contributed to fragmentation of rudimentary
organisational learning processes (Hale et al., 2002, Lodge, 2003).
Thus, learning from railways-related accidents is no longer a monopoly of one of the
stakeholders in the railway industry. Lessons to be learned will be different for different
stakeholders; opportunities to learn effectively will also be different. Some risks identified
through learning from accidents or incidents might better controlled by another stakeholder.
All these considerations indicate the necessity to conceive organisational learning from
railway-related accidents and (near-miss) by and for the European railway industry in order to
meet the interoperability objective. It is essential to identify what sorts of lessons can be
learned from railway incidents at targeted levels within the Europe. These classes of learnable
lessons differ for distinct levels. Starting from the collecting of raw accident/incident data
value must be added for learning, e.g. about relevant system factors, to improve management
of risks by ultimately at operational level. Higher-level learning requires data that is produced
by processing lower level event data.
Organisational learning (OL) is a systematic process by which operational surprises are
identified and analysed, corrective actions are devised and implemented, and the effectiveness
and impact of the corrective actions are monitored. An operational surprise occurs when
somebody or some monitoring system detects operational conditions that were not anticipated
and might lead to an unsafe state (Koornneef, 2000). Surprises are directly observed through
hazardous events, such as SPAD or over-speeding, however there are some which have to be
derived from benign events, such as omissions to acknowledge alarms.
There could be many different causes for a surprise, however, the primary objective of OL is
to identify manageable root causes, and devise appropriate corrective feasible measures that
effectively prevent (surprise) recurrence and/or control the operational risk within acceptable
levels. This devising is the function of `Learning Agency¿; implementation is a responsibility
of appropriate line management. Data collected, processed and stored for this purpose also
provided a sound basis for defining meaningful safety indicators.
The SAMRAIL WP2.6 Workshop on Accident & Incident Data Requirements on September
17, 2003 (Koornneef and Kingston, 2003), revealed that clear insights in contents of and
provisions for enabling effective learning from incidents by the participant's railway
organisations are largely lacking; in addition, various barrier that obstruct such effective
learning were identified.
This document addresses key issues that need to be worked out in close cooperation with
relevant stakeholders and proposes a roadmap to organisational learning from railway
accidents and incidents within the EU.
|Place of Publication||Lille (FR)|
|Publisher||SAMNET - INRETS|
|Number of pages||20|
|Publication status||Published - 2004|
|Publisher||SAMNET - INRETS|