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Chatsworth Train Collison (Human factors investigation tools recommended…

- - - - Reasonable goals in place
    - - Crew members were expected to adhere to rules
      - Crew members were expected to pay attention while on duty
      - Engineer was expected to watch for red signals
    - - Crew members experienced
        
        All members of both crews had operated their trains before and were familiar with the run
    - - High safety culture
      - Particular crew members took unnecessary risks and didn't adhere to rules
    - - No concerns, some crew were in their sixtes, but still able to perform well
      - Possible fatigue issues with older workers
    - - Assessment of fatigue management policy
      - Assessment of staff expectations
      - Assessment of staff safety culture
- - - - Small crew meant each worker had to complete their own tasks
      - Crews were familiar with the runs they were completing
      - Both crews weren't fatigued and had reasonable rest
      - Lines of inquiry
        
        Assessment of work loads
    - - Crews were familar with their tasks
      - Crews had been trained on how to use equipment
    - - Workers must have recertification
      - Workers are expected to give their full attention to their job
      - Previous qualifications and experienced required for the role
      - Lines of inquiry
        
        Assessment of job requirements and job loads
    - - No supervision on the engineers mobile phone
      - Engineer had received verbal warnings on prohibited mobile phone use but continued to use it anyway
      - Lines of inquiry
        
        Assessment of training
        
        Assessment of staff
  - - - Engineer had received no formal warnings on his prohibited mobile phone use
    - - Verbal warnings were favoured
      - Both crews would participate in morning safety meetings
    - - Sufficient training provided to both crews
    - - Train was in good condition
    - - Crew received good instructions and were prepared
    - - Assessment of safety culture
      - Assessment of disciplinary actions
  - - - working tasks were distributed amongst workers evenly, taking into account previous experience, training and qualifications
    - - Strict work policy on mobile phone use
      - Culture of acceptance for non-compliances
      - Inadequate policies surrounding human error
      - Lines of inquiry
        
        Assessment of safety culture
    - - No formal warnings issued to prohibited mobile phone use
      - No failsafe system in place for human error
      - Expected staff to not make mistakes
      - Lines of inquiry
        
        Assessment of safety systems
        
        Assessment on failsafes
        
        Assessment on staff expectations
- - - - No unsual noises
      - High visibily
      - Weather was fine
    - - Assessment of workplace culture
  - - - Hindered efficiency testing
      - Hindered performance monitoring
    - - No intervention to stop the Metrolink train 111 once it passed the red signal
    - - Assessment of locomotive design
      - Assessment of situational awareness from locomotive operating compartment
  - - - assessment of safety culture
      - assessment of task design
      - Assessment of staff expectations