The Edge Hill railway accident occurred on Sunday 9 May 1999 in Liverpool, England. An EngineersÆ scrap train struck a plant quality supervisor. This paper presents the results of a systemic analysis of the accident. The methodology has been to compare the features of the Edge Hill accident with the structural organization (i.e. systems 1û5) of a Systemic Safety Management System (SSMS) model, which has been constructed by employing the concepts of systems. A number of systemic failures have come to light. The findings are related to causal factors of failure of systems 1û5 as well asmissing channels of communication amongst those involved in the maintenance work. It is hoped that this systemic analysis will help to identify ælearning pointsÆ, which are relevant for preventing accidents; especially accidents involving track-side workers. (A) Reprinted with permission from Elsevier.
Samenvatting