The transport industry relies on maintaining high safety standards. Unfortunately commercial, time and human
performance pressures can undermine this aim.
Organisations that loose focus on safety, risk loosing public confidence and hence the viability of their company.
A vital part of the safety jigsaw is human performance
RAIL INDUSTRY CASE STUDY
The Automatic Warning System installed on all passenger trains in the UK is an example of a system that was not designed with limitations of human attention
in mind. It is a device fitted in the train cab. It sounds a bell when a clear (green) signal is passed and a buzzer when caution or danger is signalled.
The AWS is a useful safety driver system in that if the buzzer is not acknowledged by the press of a button, then the train begins to stop automatically.
However, times have changed since it was designed. In today’s commuter traffic, given the frequency of signals (spaced 1km apart), most drivers will face two
signals per minute.
Since people ‘automate’ highly repetitive behaviour, drivers can lose focus on the reasons for carrying out this repetitive task. The end result is that drivers often hear the buzzer and press the button automatically without thinking.
Limitations to the humans attention mechanism can cause fatal mistakes.
The human brain can only sustain attention in repetitive tasks for approximately
20 minutes, after which accuracy plummets.
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WIDER INDUSTRIAL INCIDENTS
Tenerife Air Disaster
Human error: assertiveness skills, hierarchy gradient, communication error
On March 27, 1977, two Boeing 747s passenger
jets collided on the runway at Tenerife North Airport.
The steep hierarchy gradient within the KLM cockpit, allowed an error made by the senior Captain to remain unchallenged by the junior Co Pilot and Engineer.
The crash killed 583 people, making it the deadliest accident in aviation history.
Southall Train Crash
Human error: situational awareness, poor sustained attention
The train crash occurred after the 10:32 Great Western Trains passenger train from Swansea to London Paddington hit a freight train. The Great Western Train departed with a defective Automatic Warning System (AWS), and then passed a red (danger) signal, preceded by two cautionary signals.
The high speed train driver failed to notice the danger signals. 7 people died and Great Western Trains were fined £1.5 billion.
Human error: rule violation, weak leadership, assertiveness by the ships bridge crew
The cruise liner deviated from its intended GPS route in order to sail close by a former Captains home on the Italian island of Giglio. The huge vessel struck rocks and capsized.
The ships Captain Francesco Schettino showed a reckless violation of company rules, disabled warning systems and showed poor leadership in the evacuation of passengers.