This report describes the development and application of a tool to establish a framework for rail participants to explore their current strengths and weaknesses for SPAD risk reduction and to provide the New Zealand Transport Agency with an overview of the rail industry as a whole. The project was commissioned by the New Zealand Transport Agency and undertaken in November 2014 to August 2015 by Interfleet, with input from rail organisations and network access providers, identified as Participant 1, Participant 2 and Participant 3.
The tool is based on concepts derived from the ‘Swiss cheese model’ of accident causation. It comprises:
The tool demonstrated that significant value can be gained by shifting organisational and regulatory focus from simple lag indicator assessment to clearly identifiable improvement opportunities as an indicator of safety system capability and reliability.
Keywords: change management, driver error, human error, human factors, resilience, risk reduction, signal passed at danger (SPAD), SPAD intervention, systems approach