Risk reduction of train accidents through daily after-work team reflection

A thirty-minute meeting of ProRail’s rail traffic management team at the end of every working day would significantly improve the way to deal with unexpected and unforeseen situations. There is a corresponding decline in the risk of (near) accidents. Team reflection sessions should be an integral part of the rail infrastructure operator’s corporate culture. This concludes Willy Siegel, based on his research into ‘Team reflection on weak resilience signals’.

This work was carried out within the framework of the ExploRail programme, in which the Netherlands Organisation for Scientific Research (NWO) and ProRail are jointly funding research for the optimization of railway management. Mr Siegel’s doctoral defence will take place on 12 January at the University of Twente.

Interactions between people and technology are becoming increasingly complex, while safety expectations are becoming ever more demanding. ProRail, the Dutch rail infrastructure operator is no exception. Researcher Willy Siegel concludes that structural knowledge sharing within teams, concerning events that occurred during the day, is the ideal source of unwritten knowledge. In addition, explicit knowledge is more important than procedures. “This is knowledge that really must be shared. ‘Weak resilience signals’ (signals that trigger analysis) are presented by a debriefing system, named Resiliencer. This enables rail signaller teams to discuss these issues, to prevent accidents in the future or to handle them more effectively.”

Willy Siegel conducted part of his research on site, at ProRail. While he was working there, a near accident occurred in the vicinity of Zaandam. In foggy weather, two trains had ended up nose to nose on the same track, at an opened bridge. On the day in question, a combination of factors was involved: an open bridge, restricted visibility due to fog, an employee who had reporting in sick during the morning, a trainee driver, visual information spread across two computer monitors (one train on the left-hand screen and the other on the right-hand screen), and so on. These coincidental circumstances and events form an illustrative ‘case’ for his findings.

Mr Siegel explains that ‘Three specific aspects of the work must be discussed during team meetings. These are performance, workload and safety. Using the debriefing system, the meeting covers every detail of the circumstances of the near accident (several of which occur every day, involving varying degrees of seriousness), in the context of these three aspects. This knowledge needs to be implemented. Every day, it is also important to record details of what went well, to help people act, anticipate, incorporate these lessons into procedures, and to learn.’

According to Willy Siegel, the events preceding near-misses are the same as those associated with real accidents. Ideally, rail traffic management will be aware of all unexpected and unforeseen events. The question is, what is a suitable subject for reflection? Weak resilience signals encourage staff to talk about events and give them due consideration. This takes place at the end of the working day, via the debriefing system (Resiliencer), which includes various aspects of resilience. Although the latter is difficult to measure, we were able to quantify a number of aspects.’

Mr Siegel takes the view that people need to focus on what is going well, rather than endlessly thinking about what went wrong. ‘Rail traffic controllers of the future must acquire the skills needed to conduct effective team reflection sessions. At the end of their working day, they will have to take on the role of operational analyst.’

Willy Siegel adds that the personal development of rail traffic controllers is not the only consideration here. Both ProRail and its processes will also need to adapt.  

Further details

A.W. Siegel carried out his research within the framework of the ‘HMI-R enabling resilience to improve the capability to cope with calamities and disruptions (RAILROAD)’ project (part of ExploRail, a joint NWO/ProRail programme). Willy Siegel was based at the Department of Cognitive Psychology and Ergonomics, part of the University of Twente’s Faculty of Behavioural, Management and Social Sciences (BMS). The main applicant was Prof. J.M.C. Schraagen.

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Joost Bruysters
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