| Authors: | Ross Owen Phillips, Fridulv Sagberg |
| Report nr: | 1066/2010 |
| ISBN: | 978-82-480-1067-8 |
| ISBN (digital version): | 978-82-480-1066-1 |
| Language: | English |
| Attachments | Summary Full report Sammendrag |
Ten incidents in which a train driver overlooks a signal are analysed in order to identify limitations in the organisational and technical systems surrounding signal approach by drivers. Systematic aggregation of case study findings reveals that hazardous signal approach is characterised by (i) deviance from the situation norm; (ii) high demand placed on the driver; (iii) driver reliance on expectations based on the situation norm. According to an accompanying survey, 83 per cent of drivers think that the development of assumptions based on routine norms is an important safety issue. Based on these findings we recommend ways to prevent drivers developing cognitive shortcuts on being exposed repeatedly to unchanging stretches of track. We report on the incidence of different signal approach incidents, according to drivers, and discuss methodological aspects of CREAM, the tool used to analyse and classify error causation in the case studies.
