16th International Railway Safety Conference The human factor

1Deutsche Bahn AG, Fritz Schröder, Safety VS

16th International Railway Safety Conference

The human factor

Dublin Castle, Tuesday 24th October

Deutsche Bahn AG

Fritz Schröder

Safety VS

2Deutsche Bahn AG, Fritz Schröder, Safety VS

Causes

Causes of irregularities in rail operations of Deutschen Bahn AG

90%human failings

10%other causes

3Deutsche Bahn AG, Fritz Schröder, Safety VS

Railway Safety Directive

Safety Management System

Safety Program 2003: safety targets and plans on how to achieve targets

1. Level crossings2. Human Factors3. Platforms...

Project ‘Investigation of railway-specific human error’

4Deutsche Bahn AG, Fritz Schröder, Safety VS

Human actions in complex systems

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

‘pointed’ end, where the direct precipitating causes of the accident will be identified

Factors that have an effect on performance

Organisational environment Organisation

GroupsTechnology

Humanbeings

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Barrier 1

Barrier x

Path of a potential accident

Jim Reason’s model of the way an accident arises (1998)– the ‘Swiss cheese’ model

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STOP

Barrier 1

Barrier 2

Barrier 3

Barrier x

Incidentoccurs

STOP

Path of a potential accident

Jim Reason’s model of the way an accident arises (1998)– the ‘Swiss cheese’ model

7Deutsche Bahn AG, Fritz Schröder, Safety VS

Organizational learning

In-depth analysis on all levels of the system

Change of organizational factors

Single-loop learning:Local, short-term changes related to the specific event

Double-loop learning:Extensive long-term learning & improvement beyond specific event

Safety-related event

Argyris & Schön, 1996; MTO, 2003

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Organizational environmentOrganizationGroup levelTechnicalHuman

Two views of human error

1. Human error = cause End of investigation What?

2. Human error = symptom Start of investigation Why?

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Safety Culture

safety as a priority rulebook conservative decisions reporting culture rejection of any actions and conditions that are unsafe learning organisation

10Deutsche Bahn AG, Fritz Schröder, Safety VS

Programme for DB Group executives at the highest level

Further development of safety culture and risk management awareness

Information and discussion about trends and developments in European and national safety requirements

Raising consciousness of the importance of safety in the rail system network

Dealing with the conflict of goals between safety, quality and economic considerations

Aims

11Deutsche Bahn AG, Fritz Schröder, Safety VS

Many thanks for your attention