16th International Railway Safety Conference
The human factor
Deutsche Bahn AG
Fritz Schröder
Safety VS
Dublin Castle, Tuesday 24th October
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Causes
Causes of irregularities in rail operations of Deutschen Bahn AG
90%
human failings
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other causes
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Project ‘Investigation of railway-specific human error’
Railway Safety Directive
Safety Management System
Safety Program 2003: safety targets
and plans on how to achieve targets
1. Level crossings
2. Human Factors
3. Platforms
...
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Human actions in complex systems
Factors that have an effect on performance
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
Organisational environment
Organisation
Groups
Technology
Human
beings
‘pointed’ end, where the direct precipitating causes of the accident
will be identified
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Path of a potential accident
Jim Reason’s model of the way an accident arises (1998)
– the ‘Swiss cheese’ model
Barrier 1
Barrier x
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Path of a potential accident
Jim Reason’s model of the way an accident arises (1998)
– the ‘Swiss cheese’ model
Barrier 1
Incident
occurs
STOP
STOP
Barrier 3
Barrier x
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Barrier 2
Organizational learning
Double-loop learning:
Extensive long-term
learning & improvement
beyond specific event
Safety-related event
Single-loop learning:
Local, short-term changes
related to the specific event
Change of
organizational factors
In-depth analysis on
all levels of the system
Argyris & Schön, 1996; MTO, 2003
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Two views of human error
1. Human error = cause
End of investigation
What?
2. Human error = symptom
Start of investigation
Why?
Organizational environment
Organization
Group level
Technical
Human
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Safety Culture
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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
 Information and discussion about
 Raising consciousness of the
trends and developments in European
and national safety requirements
importance of safety in the rail system
network
Aims
 Further development of
 Dealing with the conflict of
safety culture and risk
management awareness
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goals between safety,
quality and economic
considerations
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Many thanks for your attention
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