Classification of errors contributing to rail incidents and accidents: A comparison of two human error identification techniques

摘要

Identifying the errors that frequently result in the occurrence of rail incidents and accidents can lead to the development of appropriate prevention and/or mitigation strategies. Nineteen rail safety investigation reports were reviewed and two error identification tools, the Human factors analysis and classification system (HFACS) and the Technique for the retrospective and predictive analysis of cognitive errors (TRACEr-rail version), used as the means of identifying and classifying train driver errors associated with rail accidents/incidents in Australia. We aimed to identify the similarities and differences between the techniques in their capacity to identify and classify errors and also to determine how consistently the tools are applied. The HFACS analysis indicated that slips of attention (i.e. 'skilled based errors') were the most common 'unsafe acts' committed by drivers. The TRACEr-rail analysis indicated that most 'train driving errors' were 'violations' while most 'train stopping errors' were 'errors of perception'. Both tools identified the underlying factors with the largest impact on driver error to be decreased alertness and incorrect driver expectations/assumptions about upcoming information. Overall, both tools proved useful in categorising driver errors from existing investigation reports, however, each tool appeared to neglect some important and different factors associated with error occurrence. Both tools were found to possess only moderate inter-rater reliability. It is thus recommended that the tools be modified, or a new tool be developed, for complete and consistent error classification.