A systemic analysis of the Edge Hill railway accident.
Аннотация
The Edge Hill railway accident occurred on Sunday 9 May 1999 in Liverpool, England. An Engineers' scrap train struck a plant quality supervisor. This paper presents the results of a systemic analysis of the accident. The methodology has been to compare the features of the Edge Hill accident with the structural organization (i.e. systems 1-5) of a Systemic Safety Management System (SSMS) model, which has been constructed by employing the concepts of systems. A number of systemic failures have come to light. The findings are related to causal factors of failure of systems 1-5 as well as missing channels of communication amongst those involved in the maintenance work. It is hoped that this systemic analysis will help to identify 'learning points', which are relevant for preventing accidents; especially accidents involving track-side workers.
Предметные рубрики MeSH
Подготовка и перевод публикации
Обработка статьи · этапы, ошибки и управление
Ошибки и ограничения
История · было → стало
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