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Getting to the underlying causes of SPADs
11/02/2021
When we look for the underlying and contributory factors of a Signal Passed At Danger (SPAD), our understanding of the incident becomes much clearer. By considering both individual and organisational factors, we can make suitable recommendations to reduce the risk of such an event happening again.
SPAD investigations have traditionally focused on understanding what happened. They identify each step in the sequence of events that lead to the unwanted incident. Identifying the ‘what’ is important but does not always give us the full story. We also need to find out why each step happened. This approach often requires more time and perseverance, but the reward is a clearer understanding of the underlying causes.
