Re: British Accident 1sr Report Out - Thames Driver Not Being Blamed At This Point

[Eddie Oliver <eoliver@efs.mq.edu.au>]

Derick Wuen wrote:

> 
> I still think its chilling that fundamental safety gets abbreviated,
> summarised and now according to Eddie, categorized ...... A minor SPAD, a
> semi-minor SPAD, a serious SPAD, a Ladbroke Grove SPAD....

The simple fact is that a very high proportion of SPADs really ARE minor
- e.g. very minor misjudgments of braking, which is exactly why overlaps
are there. A blanket identification of all SPADs as being worthy of
dismissal, for instance, completely overlooks the realities.

Moreover there are a variety of other SPAD categorisations which are
essential, even if you don't like them. For instance there are SPADs
which are in no way the fault of the driver, e.g. when a signal goes
back to stop in the face of a driver and there is no way he could stop
in time.

> The use of the acronym desensitizes the meaning such that the psychology is
> all wrong for safety culture.
> 
> If a signal is passed at danger and it "does not matter", then remove that
> signal... its obviously superfluous.

Rubbish.

Nobody is saying that a SPAD "doesn't matter", because it shows that
something was wrong somewhere. However the whole principle of having
overlaps beyond signals at stop is to protect against minor errors of
judgment or of minor physical defects in trains, rail conditions etc.
Every SPAD should be investigated, but it does not necessarily have to
be regarded as a major calamity. The whole point is to learn from all
incidents.

The more draconian you make the disciplinary policies, the less likely
it is that incidents will be reported, and then you lose the very
benefits which incident investigation should lead to. 
 
> I suggest that a target for rail operations should be zero tolerance to
> passing a signal at danger, and not substitute categorization, statistics
> and acronyms for safety management.

And I suggest that although you can impose a target, your approach of
draconian disciplinary action is absolutely in the wrong direction.

Indeed safety management involves, as a major feature, having the full
co-operation of the staff. Your approach to safety management creates a
confrontational situation which is the exact opposite of what is
required for a collaborative enhancement of safety.

Eddie Oliver