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Exploring the structure and content of pro formas for signal passed at danger incidents in Australia and New Zealand

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posted on 20.10.2021, 21:44 by Anjum NaweedAnjum Naweed, Lorelle BowditchLorelle Bowditch, Janine Chapman, Jillian Dorrian, Nora Balfe
In rail transportation, managing and mitigating the risk of Signal Passed at Danger (SPAD) incidents is a perennial challenge, with causation reflective of a systems issue. However, very little research has evaluated the role of SPAD Pro Formas—the documents used to collect and analyse information during investigation. A total of 208 internal investigation reports were obtained for SPADs occurring over four years (2014–2018) from 10 organisations across Australia and New Zealand. Results revealed large variation across SPAD Pro Formas, and a notable paucity of multifactorial explanations for SPAD causation, creating key questions around organisational learning.

History

Editor

Black NL; Neumann WP; Noy I

Volume

222

Start Page

143

End Page

153

Number of Pages

11

ISBN-13

9783030746100

Publisher

Springer

Place of Publication

Cham, Switzerland

Open Access

No

External Author Affiliations

Flinders University; University of South Australia; The University of Dublin, Ireland

Author Research Institute

Appleton Institute

Era Eligible

Yes

Parent Title

Proceedings of the 21st Congress of the International Ergonomics Association (IEA 2021): Volume IV: Healthcare and healthy work