Do we really learn from railway occurrence investigations? A South African railway industry perspective

Abstract

In South Africa, railway occurrence numbers have remained unchanged over recent years despite stakeholder goals aiming for zero occurrences, suggesting that there is an important need to examine why the numbers have not decreased. This is despite accidents being investigated by the various stakeholders in the rail socio-technical system. A failure to properly identify the underlying causes for incidents may be a possible reason for the number of recurrences. If occurrences are being investigated, why then do the number of occurrences remain largely unchanged? It is proposed that perhaps there are systemic factors within the railway system that influence the investigation process and therefore its effectiveness. Rasmussen’s (1997) Risk Management Framework is used to illustrate the South African railway system and to determine the systemic factors for each level of the system impacting on the effectiveness of occurrence investigations. A qualitative, multi-method approach was adopted. The research highlighted that there are indeed systemic factors that hinder the system’s ability to facilitate a learning culture. Results suggest that there is a distinct lack of mutual trust, transparency, feedback, and sharing of information, and no just culture across the entire system. The results of this research indicate that in the railway system, learning from previous accidents does not always happen. This is largely attributed to a number of systemic factors inherent in the larger railway system that influence the effectiveness of the entire investigation process. It is concluded that failure to identify what really happened during an occurrence and therefore the validity of the recommendations impacts on the system’s ability to learn from such events.