Reducing the risk of error involving machine controllers, on-track plant, or new in-cab technology
Incidents involving OTP and the MC role are increasingly becoming a concern on the railway. On 2 May 2021, two road-rail vehicles collided while travelling on the same track near Ramsden Bellhouse. As a result, one of the operators of the OTP suffered life-changing injuries. The RAIB report into this accident highlighted three key areas in need of review and improvement.
These were about accident and incident investigation and infrastructure safety. Industry needed to:
- Clarify the role and responsibilities of an MC where OTP is travelling
- Improve learning from previous accidents and incidents that involved OTP
- Understand human factors dimensions of technology so that the risk of striking obstacles was reduced.
RSSB was asked to investigate and provide a solution by the Mechanical and Electrical Engineering Networking Group (M&EENG).
The RSSB human factors team investigated the role and responsibilities of an MC. They also reviewed past accident reports that involved OTP to identify ways to improve learning. They assessed OTP cab design within the circumstances of the Ramsden Bellhouse accident to identify system induced and human error.
The human factors team did reviews of procedures, also called ‘work as prescribed’. They did observations of ‘work as done’. They also facilitated interviews and held collaborative workshops. Railway management and frontline staff were both included in the interviews and workshops. This enabled the team to get insights into the issues from both. Control and interface surveys were used to find human factors challenges. A systematic human error reduction and prediction approach was also used.
This project gave a formal response to the RAIB recommendations after the Ramsden Bellhouse incident in 2021. It gave the Infrastructure Safety Leadership Group and M&EENG solutions for the three issues in that event.
- The project clarified what the MC must do. The MC needs more support when controlling a travelling movement on track with OTP. Updated procedure documents and new guidance are needed so that industry has a shared position on these issues.
- The principal contractor community needs to have better awareness of accidents and incidents that involve OTP movements.
- The management and assessment of new in-cab technology needs to be better. This project developed a human factors error log to help assess the potential effectiveness of this to reduce the risk of striking obstacles.