Conference paper
Learning from accidents: developing a contributing factors framework (CFF) for the rail industry
Proceedings of the 47th Annual Conference of the Human Factors and Ergonomics Society of Australia, pp.1-6
Annual Conference of the Human Factors and Ergonomics Society of Australia (HFESA), 47th (Sydney, Australia, 07-Nov-2011–09-Nov-2011)
Human Factors & Ergonomics Society of Australia Inc.
2011
Abstract
Background: In the Australian rail industry, safety performance data are currently collected by accredited rail organisations and delivered to the Rail Safety Regulator of the relevant jurisdiction. These data are gathered using specified criteria which categorise information about rail safety occurrences in terms of 'what' occurred. Information regarding 'why' the event occurred is not gathered systematically. The rail industry, in seeking to protect itself from the system failures that lead to incidents and accidents, requires rich information about these failures. Key to achieving this is the conduct of systems investigations. The aggregation of data from these investigations can provide valuable information about system-wide safety issues. Aims: A national project overseen by the Rail Safety Regulators' Panel (RSRP) developed a "Contributing Factors Framework" (CFF) to capture information on systemic contributors. Method: Human Factors, investigations and rail operations specialists developed the framework based on Reason's Model of Organisational Accidents. Following road-testing, the framework was released in 2009 with version 2 released in 2011. Results: Aggregated CFF data can be used to direct efforts to improve safety in organisations. Other benefits include improved investigation skills and outcomes, a structured and standard frame of reference for discussing investigation outcomes and enhanced organisational learning and communication by adopting the framework's common language. Conclusions: The CFF has been well received in the industry and is in use by regulators, rail companies and investigators. It is being monitored in a review process. An overview of the framework is provided. Issues in terms of the balance between science and practice are discussed.
Details
- Title
- Learning from accidents: developing a contributing factors framework (CFF) for the rail industry
- Authors
- Elizabeth Grey (Author) - Transport Safety VictoriaB Klampfer (Author) - Independent Transport Safety RegulatorGemma J M Read (Author) - Transport Safety VictoriaN Doncaster (Author) - Office of the Safety Regulator South Australia
- Contributors
- Rebecca Mitchell (Editor)
- Publication details
- Proceedings of the 47th Annual Conference of the Human Factors and Ergonomics Society of Australia, pp.1-6
- Conference details
- Annual Conference of the Human Factors and Ergonomics Society of Australia (HFESA), 47th (Sydney, Australia, 07-Nov-2011–09-Nov-2011)
- Publisher
- Human Factors & Ergonomics Society of Australia Inc.
- Date published
- 2011
- ISBN
- 0980306396
- Organisation Unit
- Centre for Human Factors and Systems Science; School of Health - Psychology; School of Law and Society
- Language
- English
- Record Identifier
- 99450179602621
- Output Type
- Conference paper
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