1. 1Deutsche Bahn AG, Fritz Schröder, Safety VS 16th International Railway Safety Conference The human factor Dublin Castle, Tuesday 24th October Deutsche Bahn AG Fritz Schröder Safety VS

2. 2Deutsche Bahn AG, Fritz Schröder, Safety VS Causes Causes of irregularities in rail operations of Deutschen Bahn AG 90% human failings 10% other causes

3. 3Deutsche Bahn AG, Fritz Schröder, Safety VS Railway Safety Directive Safety Management System Safety Program 2003: safety targets and plans on how to achieve targets 1. Level crossings 2. Human Factors 3. Platforms... Project ‘Investigation of railway-specific human error’

4. 4Deutsche Bahn AG, Fritz Schröder, Safety VS Human actions in complex systems the ‘blunt’ end (removed from the incident in terms of space and time), where it is the accompanying circumstances of an accident that will tend to be described ‘pointed’ end, where the direct precipitating causes of the accident will be identified Factors that have an effect on performance Organisational environment Organisation Groups Technology Human beings

5. 5Deutsche Bahn AG, Fritz Schröder, Safety VS Barrier 1 Barrier x Path of a potential accident Jim Reason’s model of the way an accident arises (1998) – the ‘Swiss cheese’ model

6. 6Deutsche Bahn AG, Fritz Schröder, Safety VS STOP Barrier 1 Barrier 2 Barrier 3 Barrier x Incident occurs STOP Path of a potential accident Jim Reason’s model of the way an accident arises (1998) – the ‘Swiss cheese’ model

7. 7Deutsche Bahn AG, Fritz Schröder, Safety VS Organizational learning In-depth analysis on all levels of the system Change of organizational factors Single-loop learning: Local, short-term changes related to the specific event Double-loop learning: Extensive long-term learning & improvement beyond specific event Safety-related event Argyris & Schön, 1996; MTO, 2003

8. 8Deutsche Bahn AG, Fritz Schröder, Safety VS Organizational environment Organization Group level Technical Human Two views of human error 1. Human error = cause End of investigation What? 2. Human error = symptomStart of investigation Why?

9. 9Deutsche Bahn AG, Fritz Schröder, Safety VS Safety Culture  safety as a priority  rulebook  conservative decisions  reporting culture  rejection of any actions and conditions that are unsafe  learning organisation

10. 10Deutsche Bahn AG, Fritz Schröder, Safety VS Programme for DB Group executives at the highest level Further development of safety culture and risk management awareness Information and discussion about trends and developments in European and national safety requirements Raising consciousness of the importance of safety in the rail system network Dealing with the conflict of goals between safety, quality and economic considerations Aims

11. 11Deutsche Bahn AG, Fritz Schröder, Safety VS Many thanks for your attention