Helping improve investigations into signals passed at danger (SPADs)
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New guidance and research are helping Network Rail and train operating companies to put more focus on the underlying causes of signals passed at danger (SPADs) and a ‘just culture’ in their investigations.

Since the Ladbroke Grove accident in 1999, no one has died as a result of a SPAD.   Investment in the Train Protection and Warning System (TPWS), together with ongoing analysis of the risk, better briefing and training of drivers form just part of industry’s effort to bring the risk from SPADs down.

However, there are still about 300 SPADs a year, and each represents a situation where something, somewhere, didn’t go to plan.  In investigations, knowledge about the role of human factors is still inconsistent and there can be a temptation to focus solely on the train driver and not on the role of underlying causes.

To address this, we reviewed SPADs from a human factors perspective, looking at reports, live investigations, processes, and running workshops with drivers, signallers and managers.  

Ten key incident factors were used to focus on the risks which make SPADs more likely. The study identified the following as key underlying causes: signal design and layouts, driver competence management - particularly route knowledge, personal factors - particularly fatigue and health, driver workload, non-technical skills, safety critical communications, and the things that cause trains to approach red aspects in the first place.

By looking at these factors, it’s easier for investigations to tease out the underlying problems which lead to SPADs. 

The review has led to a range of outputs to help organisations improve SPAD investigations.

New guidance, ‘How to manage SPAD risk better - a guide for directors’ aims to provide practical advice to senior industry managers to improve SPAD investigations.  Electronic copies have been sent to operational safety leads in Network Rail and train and freight operating companies by Steve Murphy the Chair of the SPAD Risk Reduction Strategy Group, and Managing Director at MTR Crossrail.

The guide is also available on SPARK, alongside a full report of the ‘Industry Human Factors SPAD Review’, and a shorter summary report from the workshops.

The work will be mentioned in the RED 44 video due for release in March, and in an article reflecting on the accident at Purley in 1989 in the next issue of Right Track due for publication in February.

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