Human Error

Column juni 2012

Human Error

The traindriver missed a red sign. The low standing sun diminshed the view was stated in the news. In the mean time, the railway company declared that the sight was clear and good. Prorail indicates that the railway track at the spot of the incident has been inspected recently: it was in a good condition. They leave others to conclude hat it therefore only could have been a Human Error. IS IT? Prorail on TV: 2 trains at the same track driving towards each other is a very rare event. "how often does it happen"is the logical question of the interviewer. "Two to three times a year". WHAT? This is a large risk, the error must be present deep in the railway organisations. Human Error? This goes far beyond. Why does trains pass a red sign 50- 100 times a year? If the personell is brought in positions that conduct unsafe acts is almost unavoidable, than the management is responsible. The conditions for unsafe acts need to be managed in a better way. 

The Dutch Railways use Tripod for incident analysis. I have the impression that the added value of it: adressing the Latent Failures in the organsiation and correcting them is not yet reached. Let we stop talking about Human Error is an easy way. Perform a serious Tripod and correct the underlying Latent Failures. If not: we can wait for the next so called human error case. But at the cost of what?