16th International Railway Safety Conference The human factor

1. 16th International Railway Safety ConferenceThe human factor Deutsche Bahn AG Fritz Schröder Safety VS Dublin Castle, Tuesday 24th October Deutsche Bahn AG, Fritz Schröder, Safety VS

2. Causes • Causes of irregularities in rail operations of Deutschen Bahn AG 10% other causes 90% human failings Deutsche Bahn AG, Fritz Schröder, Safety VS

3. 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 ... Deutsche Bahn AG, Fritz Schröder, Safety VS

4. 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 Deutsche Bahn AG, Fritz Schröder, Safety VS

5. Path of a potential accident Jim Reason’s model of the way an accident arises (1998) – the ‘Swiss cheese’ model Barrier 1 Barrier x Deutsche Bahn AG, Fritz Schröder, Safety VS

6. Incident occurs STOP STOP Path of a potential accident Jim Reason’s model of the way an accident arises (1998) – the ‘Swiss cheese’ model Barrier 1 Barrier 2 Barrier 3 Barrier x Deutsche Bahn AG, Fritz Schröder, Safety VS

7. 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 Deutsche Bahn AG, Fritz Schröder, Safety VS

8. What? End of investigation 1. Human error = cause 2. Human error = symptom Start of investigation Why? Organizational environment Organization Group level Technical Human Two views of human error Deutsche Bahn AG, Fritz Schröder, Safety VS

9. Safety Culture • safety as a priority • rulebook • conservative decisions • reporting culture • rejection of any actions and conditions that are unsafe • learning organisation Deutsche Bahn AG, Fritz Schröder, Safety VS

10. 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 • Further development of safety culture and risk management awareness • Dealing with the conflict of goals between safety, quality and economic considerations Programme for DB Group executives at the highest level Aims Deutsche Bahn AG, Fritz Schröder, Safety VS

11. Many thanks for your attention Deutsche Bahn AG, Fritz Schröder, Safety VS