In case of emergency press button B … or is it C?

1. In case of emergency press button B … or is it C?

2. Real consequences for real people

3. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

4. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

5. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

6. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

7. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

8. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

9. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailingloco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

10. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailingloco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

11. Let’s find the broken bits .. • Radio active in trailing locomotive • Driver didn’t log on • Train controller didn’t register train • New train controller registered trailing loco • No communication with driver to register • Train controller didn’t make broadcast call • Train controller didn’t have phone numbers • Incident was not given priority • Repeat of similar incidents.

12. Everyone wanted to work safely. None of them did. The entire system had drifted. Drifted into failure.

14. Mobile phones • A great convenience, or a lethal distraction?

15. Mobile phones • They are a part of life for virtuallyeveryone.

16. Mobile phones • Do we ban them, or embrace them?

17. Mobile phones • Or both?

18. Mobile phones • Or both?

19. Mobile phones • In Japan they have been used since 2004

20. Mobile phones • In other countries they are banned …

21. Mobile phones • except when it is convenient for the railway.

22. Mobile phones • We have changed.

23. Mobile phones • We cannot hold back the tide. • Embrace the change and make it safe!

24. What is different?

26. Mobile phones • This could be dangerous!

30. Knowledge and error flow from the same mental sources, only success can tell one from another. Ernst Mach, 1905

31. Strathfield

32. Homebush

33. Summit Tunnel

34. Lewes

35. Hexham

36. Recommendations for Success

37. Train in realistic situations • Use simulators • Test a range of scenarios • Practice until it is natural • Assess regularly. • Recommendations for Success

38. Train in realistic situations • Use simulators • Test a range of scenarios • Practice until it is natural • Assess regularly. • Recommendations for Success

39. Train in realistic situations • Use simulators • Test a range of scenarios • Practice until it is natural • Assess regularly. • Recommendations for Success

40. Train in realistic situations • Use simulators • Test a range of scenarios • Practice until it is natural • Assess regularly. • Recommendations for Success

41. Train in realistic situations • Use simulators • Test a range of scenarios • Practice until it is natural • Assess regularly. • Recommendations for Success

43. In case of emergency, press button “A”