Rail Safety: Human Factors and Policy

This assignment delves into the critical issue of rail safety by examining the significant role human factors play in accidents. It highlights how poor communication structures, disregard for safety protocols, and lack of individual accountability contribute to these incidents. The document stresses the need for robust policies and regulations, effective resource allocation, comprehensive training programs, and transparent communication channels to minimize risks and enhance overall rail transport safety.

Running head: TRAIN CRASHES
Train crashes in Australia and overseas
Student’s name:
Institutional affiliation:

TRAIN CRASHES
Introduction
Breach of safety regulations has for a long time been a key factor that has resulted in
numerous accidents that have caused human death and suffering in Australia and around the
world. This has not only caused train crashes and mishaps but also other major types of accidents
that have caused massive loss of human life and tragedy. The improper observance of security
and safety protocol has therefore been a key factor that has contributed highly in these accidents
and hence should be addressed as a mitigation measure in preserving human life. Lack of
observance of basic safety practice and change in policy have therefore been cited as major
causes of both minor and major accidents. Addressing of the same could be a step forward in the
achievement of reduced tragedy caused by the breach of security regulation. The report is
therefore going to provide an example of an accident that was as a result of lack of accountability
and responsibility leading to breaches in safety protocol leading to a catastrophe. It will also
discuss the relevant literature concerned with the incident and also give in detail the safety
breaches that led to the incident occurring.
The adherence of proper safety procedure before, on and after every commute by the
transport services is a considerably major step towards providing safer transport solutions for
commuters. Small mistakes have been made before and they went ahead to cause disasters of
shocking proportions (Naweed.2013). These accidents are therefore usually mainly predictable
going by past incidences and occurrences. No accident either minor or major is acceptable as all
of them cause losses. They therefore should be prevented in any way possible. Human error
resulting from assumption of basic safety protocol should therefore be minimized or else
removed completely.
The Clapham Junction Incident

TRAIN CRASHES
A crowded commuter train ran straight head-on into the rear of another stationary train at
Clapham Junction on the 12th of December 1988 causing massive loss of human life and injury to
many more. The consequence impact of the collision moved the first train causing it to hit
another oncoming train causing the tragic death of 35 people instantly and with more than 500
other injured. The incident took place around the train station just a paltry two signals away. A
technical error occurred causing a failure in the signaling process at the station. The stop sign
which should have been signaled to the first train was not working due to some electrical failure.
The wiring of the whole electrical set-up was just done recently but it was vividly clear that that
it was a shoddy piece of work. The fuse end of the wire was left connected while the relay end
was also not disconnected as required. The whole new wiring work was done during the week
and the connections made over the weekend. Part of the job required some wire to be removed
completely from the terminals at both ends. These are the relay and the fuse end. They should
have been both disconnected completed and tied back to ensure no form of contact whatsoever.
This was however tampered with in another job the next week leading to renewed contact of the
wires. The circuitry was therefore interfered with by this careless readjustment leading to
massive loss of life.
Safety breaches that caused the accident
It is evident that there was clearly a string of safety breaches that caused the occurrence
of the train carnage at Clapham Junction. These breaches if taken into account and if addressed
as required through proper regulation and policy could prevent any other incidents, reduce the
death toll and other drastic consequences that took place brought about by these breaches. The
lack of accountability and clarity on job responsibility by the staff was a key breach in safety
precautionary measures. The relevant technical personnel and technicians in charge of the wiring

TRAIN CRASHES
and signaling at the station did not commit to their job as required. The management therefore
failed in their duty to conduct mandatory wire counts leaving all the work to junior staff who
were probably highly inexperienced.
Another safety breach was the failure by the organizational restructuring to take into
account the resources needed to make the new structures to work as they were meant to. There
was no proper consultation procedure and planning which would have been critical in preventing
small hitches along the way. The chief engineer responsible for signal works just assumed that
everything would be done as required by the other engineering personnel under his supervision
hence creating a responsibility vacuum. The lack of proper communication and massive failure
in management leadership was also another major security breach in the incident. The
communication set-up in the organization was below par and hence miscommunication along the
chain as there was no formal communication. The train staff and other station personnel had
undergone a major reorganization and were therefore adjusting to their new positions.
Inadequate training was also a safety breach as improper training or lack of necessary
skill thereof by the relevant staff could cause irreversible damage owing to small mistakes that
have major impacts (Baysari,Mclntosh and Wilson ,2008). An assumption of competence and
efficiency was effected by the senior engineers upon the junior staff as they delegated their
duties without ensuring that the personnel under them and their relevant departments were
properly trained. The senior technician should have been held accountable for the wiring
problems as it was his primary concern to ensure everything was in perfect order for operations
to work as they should.
There was also failure to audit and therefore and therefore safety auditing was not a part
of their organizational structure. The institutions management also ignored past mistakes that had

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caused other incidents at the station and therefore had only themselves to blame for not
correcting past mistakes. The warning signals from the previous accidents should have been
taken seriously and mitigation measures should have been effected immediately. Three years
prior to this incident, there had been a similar signaling failure at the station after rewiring was
done. They therefore should have been more careful considering the past failure of the system.
Considering the past issues should have been taken into account and hence the incident
could have been avoided. Ignoring of established safe systems was also a factor in the occurrence
of the incident. One example of these ignored established systems was that the proper procedure
for particular rewiring detail was not followed as needed. There were also no independent wire
counts done as was required by protocol and the redundant wires were neither disconnected nor
tied back as required. Other modifications on the signaling and wiring that should have been
done on the job were not done as required and no further consultation was done.
Conclusion
The Clapham Junction accident is just another one case caused by serious human error and lack
of accountability by the personnel concerned ensuring safety is observed. Taking into account
past mistakes and warnings from incidents in the past that had taken place in a similar pattern
should have been used as a platform to avoid the incident. Sealing al loopholes that brought
about breaches in security and safety protocol could have been a key concern of the organization.
It is clearly evident that the problem of safety breaches is more disastrous than people choose to
accept. Reflecting seriously on these underlying issues, it is very clear that people did not really
take their responsibilities as seriously required for everything to be in a required order. When
poor leadership is given charge at such critical institutions that deal with transporting human
souls, it is a big mistake (Freeman and Rakotonirainy, 2015). The presence of poor

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communication structure is also another contributory issue that should be taken seriously to
avoid misunderstanding and poor workmanship. Poor communication results in disconnected
organization and hence ineffective results from the relevant staff. Ignoring warnings from the
past seriously can lead to heart breaking tragedies. The serious consideration of minor safety
protocol could go a long way in saving human lives.
Policy and regulation concerning safety breaches that cause loss of human life and other
catastrophic incidences should be enforced by the relevant authorities. Individuals working in the
specific departments should at all times be held accountable for mistakes that cause problems
under their supervision. They should be made to face consequences in order to effect serious
work ethic amongst personnel. The organization concerned should also synergize and utilize
effectively the resources under their disposal in provision of safe transport systems for
commuters. Proper communication channels are also necessary for safety to be observed in
accordance to set policy. Proper communication either from the top down or vice versa give an
environment of understanding and accountability to every personnel responsible for a certain
task. Proper auditing of all safety procedures as required should also be done as effectively as it
is required. The organization should therefore have proper auditing procedure at all time. Proper
training of their personnel should also be ensured to impact necessary skill and expertise in their
specific lines of duty.

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References
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contribution to railway accidents and incidents in Australia. Accident Analysis &
Prevention, 40(5), 1750-1757.
Salmon, P. M., Lenné, M. G., Read, G. J., Mulvihill, C. M., Cornelissen, M., Walker, G. H., &
Stanton, N. A. (2016). More than meets the eye: using cognitive work analysis to identify design
requirements for future rail level crossing systems. Applied ergonomics, 53, 312-322.
Freeman, J., & Rakotonirainy, A. (2015). Mistakes or deliberate violations? A study into the
origins of rule breaking at pedestrian train crossings. Accident Analysis & Prevention, 77, 45-50.
Salmon, P. M., Read, G. J., Stanton, N. A., & Lenné, M. G. (2013). The crash at Kerang:
Investigating systemic and psychological factors leading to unintentional non-compliance at rail
level crossings. Accident Analysis & Prevention, 50, 1278-1288.
Australia, S. W. (2014). Work-related traumatic injury fatalities, Australia 2013. ACT: Canberra.
Naweed, A. (2013). Psychological factors for driver distraction and inattention in the Australian
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