Tragedy on grade crossing : driver failure or systemic fragility? Paper presented at IEA 2012, 18th World congress on Ergonomics : designing a sustainable future, held in Recife, Brazil, February 12-16, 2012.

Author(s)
Gomes Reis Lopes, M. Andrade de Gouveia Vilela, R. Muniz de Almeida, I. Lopes Mioto, O. Batista Conti Takahashi, M.A. & Oliveira Perin, F.
Year
Abstract

In 2010, an accident occurred in Americana-SP, Brazil, involving two trains and one bus on a Grade Crossing, when 10 people died and 17 were injured including workers. This paper aims to analyse the accident using the Model of Analysis and Prevention of Work Accidents (MAPA). The method provides observation of work, interviews and analysis of documents to understand precedents of the event in the following stages: to understand the usual work from the involved people, the changes occurred in the system, the operation of barriers, managerial and organizational aspects. By the end, measures are suggested to avoid new occurrences. The accident took place at night in a site with insufficient lighting. The working conditions of bus drivers, train operators and watchmen are inadequate. There were only symbolic barriers (visual and acoustic signals) triggered manually by watchman upon train operator radio communication. The fragility of the barrier system associated to poor lighting and short time to trigger the signaling seem to play a critical role in the event. Contrary to the official report which resulted in guilt of the bus driver, the conclusion of the paper emphasizes the fragility of the safety system and the need of level crossing reproject. (Author/publisher)

Publication

Library number
20120382 ST [electronic version only]
Source

Work: A Journal of Prevention, Assessment and Rehabilitation, Vol. 41 (2012), Supplement 1 'Proceedings of IEA 2012, 18th World congress on Ergonomics : designing a sustainable future, held in Recife, Brazil, February 12-16, 2012', p. 3148-3154, 15 ref.

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This publication is one of our other publications, and part of our extensive collection of road safety literature, that also includes the SWOV publications.