Interfleet Technology was commissioned to carry out a project on behalf of the New Zealand Transport Agency to identify best practice international solutions for mitigating human factor causes of ‘signal passed at danger’ (SPAD). SPADs are considered by the rail industry as a major safety issue as they carry the potential for high consequence accidents which generate significant reputational risk to the industry. The recorded number of SPAD has risen in recent years and this study was commissioned to identify: • the human factor causes of SPAD that are most applicable in a New Zealand context • best practice and relevant international solutions to address the human factors involved in a SPAD • strategies for intervention to mitigate the risk of, and reduce the incidence of, SPADs in a New Zealand context • barriers and risks to implementing identified solutions in New Zealand. The first stage of the project comprised a literature review (see appendix B) of the full known range of possible human factors that can lead to a SPAD, the range of SPAD options already being utilised in rail operations and existing barriers and risks to the application of SPAD mitigations. During the second and final part of the project, the focus of the scope of work changed in response to the Steering Group’s input during the project. This led to the development and application of a SPAD strategy evaluation tool which aimed to: • provide clear descriptions of excellence and describe a mature SPAD risk-reduction programme • establish a common framework for use both by the regulator and duty holders • allow the three rail organisations participating in the trial of the tool to identify their current strengths and weaknesses against each of the tool’s dimensions • allow the rail participants to make comparisons across different areas of their organisation in approach to SPAD risk reduction • help drive continuous improvement • support shared best practice. The tool was applied in a self-assessment process by all participants. The tool enabled consideration of various SPAD reduction strategy actions and identified the areas where these were likely to deliver positive benefit, placing the emphasis on a range of contributory causes and mitigation strategies and avoiding focusing on ‘single’ events. Both Participant 1 and Participant 2 found the tool and the process useful and are using the outputs to guide their future SPAD risk-reduction strategy. Participant 3 found it more difficult to apply the tool and generally thought it less relevant to their organisation which is much less complex than those of Participants 1 and 2. The tool would benefit from minor modifications to remove less relevant points for small operators to improve applicability. One of the advantages of the tool is that it provides a dashboard of leading indicators. This is especially important for those organisations, such as small heritage operators, that may not have comparable opportunities to learn from near misses in the way that larger operators do. (Author/publisher)
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