Govia Thameslink Railway’s Justin Willett considers operational incidents that can lead to SPADs down the line.
We have often focused on SPADs, what can cause them and how to prevent them. However, SPADs are only one of the operational events that import risk, albeit one of the biggest.
Other events include station overruns, stop shorts, wrongside door openings, and fails to call. Then there are speed exceedance and TPWS activations. All have their own level of risk, but do we really understand these and have a proportionate response?
What’s the real risk of a fail-to-call or, if we’re honest, a forgot-to- stop? What’s the difference between a stop short where the driver recovers and prevents doors being opened, and a pass comm being pulled that stops the train in the same place?
Is the real risk the outcome, or the error? Previous research indicated drivers who’ve had two or more station stopping incidents are significantly more likely to go on a have a SPAD.
Analysis at Govia Thameslink Railway found that over 50% of drivers who had a SPAD, had another incident within the last 12 months. So, does our analysis really get behind such errors and provide drivers with support, or are we too focused on the event?
Anyone who has worked with me will know that when ‘only’ and ‘just’ are applied to incidents this can significantly rob us and the driver of much-needed understanding and support. The driver was ‘only’ xx mph over the TPWS, rather than focusing on how the train was being driven beforehand, or ‘just’ xx mph over the speed restriction, rather than what may have caused it.
Within these incidents, are we also recognising good practice for recovering? For example, a driver stopped short but realised and didn’t open the doors. Most, if not all such incidents, are genuine mistakes, and although each may have different levels of potential consequence, the errors can have some common factors between them.
Are we turning mistakes into crimes? Or are we using the tools available for our development plans, the cognitive underload toolbox, and the various non-technical skills resources? If a technique is put in place to prevent these incidents, how do we confirm its effectiveness
Highlighting a diagram for unusual stops, crossing off stations, having a formation reminder, for instance, can just become decoration or an automatic task if not accompanied by other behaviours. Verbal and visual cues can help the reminder to be used to best effect rather than complied with mechanically.
Is enough focus placed on the behaviours needed to prevents the precursor event, why it happened and things that can reduce further errors? Or are we focused on getting the driver back out there as quickly as possible? We need to understand that, if managed correctly, these operational incidents can stop a SPAD later.
For more on non-technicalskills and competence systems,search ‘T1207’ on our website.For research on supporting afair culture, search ‘T1068’.
