A Metrorail train collision between Mzihlophe and Phomulong stations in Soweto in May 2011 resulted in 644 injuries. Health and safety history tends to repeat itself worldwide, writes railway safety and behavioural specialist Mabila Mathebula for SHEQafrica.com.
The driver had smashed into a stationary train, in similar circumstances as a rail accident in New Zealand in 1999. The Metrorail driver, who was not named by employers, had received previous warnings, had ignored two warning signals, and had travelled at 85km/h in a 30km/h zone.
He was dismissed for negligence, but drilling down to the root causes of a train accident is more complicated than fixing blame. Incidents arise from a combination of active failures, local factors, and organisational factors, including corporate culture.
I could only hope that all these factors had been taken into account, investigated and rectified before the driver was dismissed, writes Mathebula.
Signal Passed at Danger (SPAD)
There is no public information or report yet about relevant train movements, communications, crew changes, visibility of point indicators, compliance and monitoring reports of drivers, personnel information, and Signal Passed at Danger (SPAD) management strategy.
SPAD is the railway term for passing a signal without authority. SPAD is a word wide railway problem which has to be properly managed. David Embrey, a human factor consultant, argued in SPAD conference in London that human beings have ‘design flaws’ within them. Blame and punishment will not get us too far as we come up against inbuilt vulnerabilities.
Davis said that it is important to get systems in place to address this and make sure that vulnerabilities do not manifest as loss incidents.
Australia’s Queensland Rail approach to managing SPAD reduction includes;
• Awareness; many workers, including some drivers, were not aware of what a SPAD is.
• Awareness; poster and toolbox talk campaigns developed by drivers.
• Communication; management and union presentations at train crew depots to discuss SPAD issues and concerns.
• Communication; SPAD alerts newsletter.
• Management; SPADs standard and response drill.
• Record keeping; comprehensive SPAD reporting forms, including human factor analysis section. The human factors part is optional and is completed if the driver agrees.
• Signage; ‘In clear’ markers for ensuring trains are fully inside a loop.
• Signage; check boards as reminders.
• Signage; signal board reminders and countdown markers to signals.
• Training; ‘Safe driving techniques’ booklet.
• Training; ‘Shunting within the limits’ handbook. Many SPADs occur in sidings.
Corporate culture soul searching
The Soweto rail collision raises questions that should form part of soul searching in the section, in Metrorail, in Transnet, and in all state services. Was compliance and monitoring conducted on the dismissed train driver? Was he recertified in rules and codes? Was Train Handling Mastery tested frequently? When were formal Safety Observations done? How long has he been in the railway service? What was his health status and shift roster?
Rail safety recommendations
Below are some general rail safety recommendations, including aspects of awareness, training, supervision, management, occupational health, and fatigue management aspects.
Rail safety awards needed
Launch a William Keet Thackeray Safety award for exceptional train drivers. Every profession needs role models. For example, the nursing profession looks up to Florence Nightingale, and in medicine we have Prof Chris Barnard. Railway history is being lost daily.
Rail workers do not even know that Johan Rissik, after whom Johannesburg was named, was a distinguished railway engineer. Railway employees could hardly tell you who Sir William Wilson Hoy was. The William Keet Thackeray Award could revive train driving as a profession. Thackeray received six medals for war service.
Rail safety refresher training
Pay attention to refresher training because annual re-certification could be seen as a mere half hour, tickbox exercise.
Train control is seen by train drivers as a form of supervision. It would be dangerous if train drivers saw themselves as being self-supervising.
Performance feedback is of overpowering importance. More often than not when positive feedback occurs, it is usually in relation to commercial objectives. Drivers need to be given timeous feedback on job performance. Drivers also need negative feedback with guidance.
The primary area focused on by a number of managers relate to ways to improve commercial performance or shunting practice. Very few relate to safety practice. Managers need to zero in on safety practice.
Management should be aware of fatigue management principles. There are times when drivers’ minds wander while driving on certain sections of track, and even times when they are in a sort of a trance, due to repetitive scenery and sound, especially light or peripheral features passing at a frequency of four per second, or 4Hertz. Mistakes are made in daydreaming or trance state.
SPAD management strategy
SPAD is ubiquitous in the railway world. PRASA should set a strategy for reducing SPAD incidents. Human Reliability Associates had drafted a Model for Assessing and Reducing SPADSs, (MARS), a sequential management model to addresses the likelihood of SPADs at various stages that drivers go through when approaching a danger signal.
Accident investigation is a titanic labour because there are many factors involved. The rail industry in South Africa is at a crossing and we shall need a strong and able crew to facilitate a safe journey.
Political transformation in South Africa had a direct impact on every nook and cranny of our society, industries and jobs. We need to be very broad in our thinking because we could end up at mechanising and not using train drivers.
The rail industry needs thinkers of great thoughts and doers of great deeds. Coercive power will not solve our safety problems, but would merely perpetuate our safety problems.
A broad based strategy is needed to address these safety challenges in rail, mining, stadiums and police service.
Another historic rail incident
When I was a railway employee finalising an accident investigating report after a driver had been fatally injured in Ladysmith due to a head on collision, I received a disturbing email from a colleague: ‘At 07:02 on Wednesday, 20 October 1999, Train 938 northbound express freight, collided with Train 919 southbound intercity express freight, which was stationary on the main line within station limits at Waipahi on the Main South Line.’
The driver of Train 919 was fatally injured, and the driver of Train 938 was seriously injured. Causal factors included “one driver’s misunderstanding of his track warrant limit, a train control system used in areas where Automatic Signalling, or CTC, is not used, and also limited effectiveness of the action taken by the operator and the regulator to minimise the possibility of such misunderstanding.”
My heart nearly missed a beat. I found my job purgatorial. Why did I choose this traumatic health and safety job?
Waipahi is in New Zealand. Rail safety challenges are worldwide, with minor differences in safety culture, technical knowledge, and accident investigation approaches.
Rail is a ‘killer application’
Railway technology had advanced in 190 years, but accidents continue at about the same rate as before. Advent of railroads in the 1820s was a ‘killer application’ (Dawner & Mui, 1998), one that alters the way society functions.
Early railway culture aimed at utility, not safety. Wagons were first drawn by horses and safety was not crucial. Stream locomotives since the 1830s brought increased weight, and safety became a crucial element.
Railway culture lesson
In corporate culture and industrial culture, the past is an integral part of the present and future, since culture is self-sustaining. To ignore the past is to destroy the future, and to dwell on the past is to rob the future.
In 1924 a lad of 16, William Keet Thackeray, joined the SA Railway as a labourer in Braamfontein. He was destined to become one of the SAR’s special grade drivers. A year later, he became a cleaner at running sheds in Braamfontein. Going to Germiston on transfer, he was took promotion to a fireman in 1928.
Only four years later he returned to Braamfontein, and stayed there for his working life. As a stoker, he fired to driver Ashworth, known in Braamfontein as ‘Hellfire Jack’. In 1934, William Thackeray at age 27 passed his driver’s examination.
In 1950 he was promoted to Driver Special Class, driving mostly passenger trains like the White Train and Blue Train. Thackeray was the first driver at Braamfontein to be awarded a Gold lapel badge for an unblemished record of service, in 1960.
The badge required at least 15 years accident free, among other qualifications, like favourable reports from a Locomotive Superintendent, Locomotive Foreman, and Locomotive Inspectors. These reports covered reliability, co-operation, courtesy, and efficiency.
Due to retire in 1962, he opted for an additional three years, logging 41 unblemished years of service. The Railway Safety Regulator, PRASA and Transnet should take a leaf out of driver Thackeray’s book. Safety takes training, discipline, time, constant effort, and a corporate culture that values safety.
• Mabila Mathebula (BA Univ North West, BA Hon UNISA, MBA Midrand Graduate Institute, Post Grad Dipl Advanced Project Management from Cranefield College) is completing a PhD in Organisational Behaviour at University Pretoria, with a thesis on turnover intentions.
Mathebula was a member of the Transport Research Board (TRB) based in Washington DC, USA, and was a member of the Southern African Railway Association (SARA) Safety Committee. Mathebulsa was instrumental in the establishment of the Rail Safety Regulator in South Africa.