The good, the bad, and the lost: a meta-analysis of rail signal passed at danger incident investigations using AcciMaps and systems thinking

Anjum Naweed; Teal  Evans; Gemma Read; Paul Salmon; Brian Thoroman

doi:10.1016/j.ssci.2025.107054

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The good, the bad, and the lost: a meta-analysis of rail signal passed at danger incident investigations using AcciMaps and systems thinking

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The good, the bad, and the lost: a meta-analysis of rail signal passed at danger incident investigations using AcciMaps and systems thinking

Anjum Naweed, Teal Evans, Gemma Read, Paul Salmon and Brian Thoroman

Safety Science, Vol.195, pp.1-18

2026

DOI: https://doi.org/10.1016/j.ssci.2025.107054

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Abstract

rail safety

system error

contributory factors

cognitive disengagement

corrective actions

system learning

Signal Passed at Danger (SPAD) incidents, though infrequent, remain a serious threat to rail safety. While often investigated as discrete operational events, SPADs are symptomatic of deeper system conditions. Investigations tend to follow linear logics of human error and focus corrective actions on individual behaviour—especially that of the train driver. However, such approaches may obscure rather than reveal meaningful system-wide learning. This meta-analysis used the AcciMap technique to analyse and aggregate findings from SPAD investigation reports (N = 49), offering a unique holistic perspective. A total of 859 contributory factors were identified (∼17 per SPAD), with most (∼62 %) reported to occur at the level of physical processes and actor activities. The largest aggregate contributory factor being attributed to SPADs was driver cognitive (dis)engagement (63 factors). Thematic aggregation revealed four themes: (1) A signal lost in the noise, relating to information overload in the rail environment and inevitable separation of human attention from signals; (2) Lost in translation, highlighting interchangeable and indistinct use of labels and concepts employed during investigation; (3) Lost in the brake down, reflecting a dominant narrative of driver (in)action and wrong-doing; and (4) Lost in the loop, pointing to surface-level corrective actions that repeated what was expected rather than redesign ineffective controls. Findings are discussed by reflecting on the question: “what might SPADs be trying to teach us?” By shifting the analytical lens from individual to system, this study challenges dominant narratives of driver blame and considers whether current investigations genuinely reflect systems thinking or merely perpetuate an illusion of learning.

Details

Title: The good, the bad, and the lost: a meta-analysis of rail signal passed at danger incident investigations using AcciMaps and systems thinking
Authors: Anjum Naweed (Corresponding Author) - Central Queensland University
Teal Evans - Central Queensland University
Gemma Read - University of the Sunshine Coast, Queensland, Centre for Human Factors and Systems Science
Paul Salmon - University of the Sunshine Coast, Queensland, Centre for Human Factors and Systems Science
Brian Thoroman - John Holland Group (Australia)
Publication details: Safety Science, Vol.195, pp.1-18
Publisher: Elsevier BV
Date published: 2026
DOI: 10.1016/j.ssci.2025.107054
ISSN: 0925-7535
Data Availability: The data that has been used is confidential.
Grants: The whole is greater than its parts: Improving rail safety through teamwork, DE160101137 , Australian Research Council (Australia, Canberra) - ARC
Organisation Unit: Centre for Human Factors and Systems Science; School of Health - Psychology
Language: English
Record Identifier: 991188345902621
Output Type: Journal article

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