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

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.