Push Button A or is it B? Alarming design Real consequences for - - PowerPoint PPT Presentation

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Push Button A or is it B? Alarming design Real consequences for - - PowerPoint PPT Presentation

May 03, 2023 108 likes •772 views

Push Button A or is it B? Alarming design Real consequences for real people If you are delivering a system or product, you should set up a register of hazards containing information about each hazard. 16.2.2 a Can we find some hazards?

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Push Button A … or is it B? Alarming design

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Real consequences for real people

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If you are delivering a system or product, you should set up a register of hazards containing information about each hazard. 16.2.2 a

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Can we find some hazards?

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Can we find some hazards?

 Broadcast emergency call not made

 Driver didn’t log on Train had not been registered for this trip  New train controller registered trailing loco  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Broadcast emergency call not made  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Broadcast emergency call not made  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to register  Train controller didn’t make broadcast call  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Broadcast emergency call not made  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t make broadcast call  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Broadcast emergency call not made  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Broadcast emergency call not made  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Radio active in trailing locomotive  Driver didn’t log on  Train controller didn’t register train  New train controller registered trailing loco  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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Can we find some hazards?

 Broadcast emergency call not made  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority by controller  Repeat of similar incidents.

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Can we find some hazards?

 Radio active in trailing locomotive  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents at same centre

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Can we find some hazards?

 Radio active in trailing locomotive  Driver didn’t log on  Trailing loco logged on from previous day  Trailing loco shown on screen as leading  No communication with driver to confirm  Train controller didn’t use backup system  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents at same centre

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Can we find some hazards?

 Radio active in trailing locomotive  Driver didn’t log on  Train controller didn’t register train  New train controller registered trailing loco  No communication with driver to register  Train controller didn’t make broadcast call  Train controller didn’t have phone numbers  Incident was not given priority  Repeat of similar incidents.

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If you are delivering a system or product, you should actively manage the hazards to closure. 16.2.2 b

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Everyone wanted to work safely. Everyone thought they had. No one did.

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The entire system had drifted. Drifted into failure.

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If you have set up a register of hazards, you should keep it up-to-date as new information becomes available. 16.2.2 c

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Incident Investigation Reports

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Packenham Radio emergency call failed. Cellular only available medium. Situation noted but no comment from investigator.

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SPAD!

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North Strathfield No response to radio call. No broadcast call. Signallers vigorously wave flags and flash lights from balcony.

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SPAD!

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Homebush

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Lewes

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Lewes

Stop train All trains stop

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Lewes

Stop train All trains stop Enter train no. _ _ _ _

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Hexham

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“training in the application of every documented procedure that may be required.” Hexham

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“the capacity to think effectively in emergencies e.g. recognising hazards other than those explicitly identified.” Hexham

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Design feature

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Or unforseen hazard

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A great convenience,

  • r a lethal distraction?
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Used in some countries …

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Banned in other countries …

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except if convenient for the railway.

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We have changed.

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We cannot hold back the tide. Embrace change and make it safe!

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What is different?

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Traditional Radio Mobile Phone Formal Informal Structured Spontaneous Open Channel Closed Channel Situation awareness Just the two of us

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Independent check Credibility Monitored, recorded May not be recorded Press to talk Find number, dial, wait Anyone can answer Correct connection? Static configuration Numbers change

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This could be dangerous!

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New Hamburg Cellular privacy used to cover error, created hazard. Grawlin Plains Incident report by phone, phone numbers not given. Asta Imminent collision, phone numbers not

  • known. 19 Dead.
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Recommendations for Success

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Understand the system

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Ensure documentation is accurate

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Train and rehearse

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Make it second nature

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  • Train in realistic situations
  • Use simulators
  • Test a range of scenarios
  • Practice until it is natural
  • Assess regularly.

Recommendations for Success

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  • Train in realistic situations
  • Use simulators
  • Test a range of scenarios
  • Practice until it is natural
  • Assess regularly.

Recommendations for Success

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  • Train in realistic situations
  • Use simulators
  • Test a range of scenarios
  • Practice until it is natural
  • Assess regularly.

Recommendations for Success

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  • Train in realistic situations
  • Use simulators
  • Test a range of scenarios
  • Practice until it is natural
  • Assess regularly.

Recommendations for Success

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  • Train in realistic situations
  • Use simulators
  • Test a range of scenarios
  • Practice until it is natural
  • Assess regularly.

Recommendations for Success

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  • Put designers through the

training simulations to verify that the system is what they think they designed.

  • Assess regularly.

Recommendations for Success

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  • Put designers through the training

simulations to verify that the system is what they think they designed.

  • Assess regularly.

Recommendations for Success

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  • Check the rule books and

procedures are relevant and accurate.

  • Are they being used?
  • Assess regularly.

Recommendations for Success

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  • Check the rule books and

procedures are relevant and accurate.

  • Are they being used?
  • Assess regularly.

Recommendations for Success

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  • Check the rule books and

procedures are relevant and accurate.

  • Are they being used?
  • Assess regularly.

Recommendations for Success

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