Article
citation information:
Nedeliakova, E.,
Lizbetinova, L., Stasiak-Betlejewska, R., Sperka, A. Application of the reason
model within risk management on railway crossings – a case study. Scientific Journal of Silesian University of
Technology. Series Transport. 2020, 109,
129-140. ISSN: 0209-3324. DOI: https://doi.org/10.20858/sjsutst.2020.109.12.
Eva NEDELIAKOVA[1], Lenka
LIZBETINOVA[2], Renata
STASIAK-BETLEJEWSKA[3], Adrian
SPERKA[4]
APPLICATION
OF THE REASON MODEL WITHIN RISK MANAGEMENT ON RAILWAY CROSSINGS – A CASE
STUDY
Summary. Despite constant
efforts to improve safety in the railway environment, various accidents and
incidents happen, resulting in material damage and in the worst case, loss
of human lives. This article emphasises the need for proper identification of
risks, their constant monitoring, and evaluation of all causes that arise at
railway crossings. Furthermore, this paper aims to apply the Reason model to
the problems of railway crossings within the case study on the railway network
in Slovakia. The timeliness of the problem lies in the possibility of
preventing such issues in the operation of rail transport using this model.
Prevention is an effective way of averting the serious consequences of
accidents in the future.
Keywords: railway transport, safety, railway crossing,
human factor failure
1. INTRODUCTION
Railway undertakings encounter different types of risk
when providing services. In general, while respecting global definitions, the
risk can also be described as a potential safety breach in rail transport. The
risk can be defined both quantitatively and qualitatively. It represents a
certain expression of the threat level. Risks can arise at all levels of
railway undertaking management and are very specific in the transport market
environment [8,11,13,20,21,22,24]. Therefore, their early identification and
knowledge of the degree of risk are essential [2]. This determines the extent
the risk can be accepted and the threshold at which it becomes unacceptable for
the railway undertaking [5].
Research has shown that the number of deaths and serious
injuries concerning rail traffic has been on the decline since 2010. However,
the elimination of railway infrastructure risks is a topical issue. From the
safety point of view, the most dangerous place on the railway track is level
crossing with a road (railway crossing). From the perspective of customer
satisfaction, each risk affects the perception and decision-making of the use
of rail transport in the future [10]. Even in the case of rail transport,
accidents have different consequences. Accidents at railway crossings where
railway and road vehicles come together have many consequences. This is due to
the irresponsible behaviour of road users. Therefore, the authors of this
research focused on the possibilities of risk elimination at railway crossings.
Risk management is an area of management that focuses on risk analysis and
mitigation, using a variety of risk prevention methods and techniques that
eliminate existing or detect future risk-increasing factors [12]. Railway staff
seek to prevent accidents and incidents by using various mnemonic techniques,
procedures, and principles [26]. This article deals with the model that was
applied in the research, which is the Reason model or the Swiss Cheese model.
This article aims to show how the Reason model can help
in rail conditions, and thus, indicate the stage of a system or individual
failure at which an accident could be prevented [14]. It describes if any
opportunity to eliminate the consequences exists. In a selected railway
accident, this model will be applied with an emphasis on the border between the
possibility and impossibility of averting the accident. Only after a thorough
risk analysis can a set of measures be adopted that will eliminate it to an
acceptable extent in the future [15]. The basic pillar is a suitable procedure
that systematically establishes steps applicable to rail transport. Presently, railway
undertakings usually take risks when an accident or safety hazard occurs, which
is, however, connected with the consequence of demanding financial measures or
even personal injury. Primarily, world-class companies invest in preventive
measures that will never be as expensive or safety-intensive as the
consequences that need to be addressed [1]. The result should be a consistent
approach to improving the quality of risk prevention measures, eliminating
uncertainty and ultimately improving customer service.
It should be remembered that the mission of railway
undertakings is to create an integrated offer of railway infrastructure
capacity and services for the transport of passengers and goods by rail based
on the highest safety, efficiency, reliability, and environmental acceptability
[7]. Risk elimination in rail transport is associated with safety and
interoperability. These are the basic pillars of the European integrated
railway area.
Risk elimination refers to the use of the human factor in
rail workplaces where the service is carried out by railway staff under the
established mode of work. This includes regular monitoring, supervision, and
supervision during working hours [23]. Further risk elimination is possible by
technical means through permanent or intermittent monitoring of critical
infrastructure elements utilising camera devices monitoring the movement of
persons, devices for signalling intrusion of the object. A combination of the
foregoing may also be used, by adopting measures aimed at eliminating
anti-social activity in the perimeter of railways, ensuring the continuity and
safety of rail transport and preventing and eliminating incidents in rail
transport. It is precisely a combination of several measures and aspects as a
means of preventing the occurrence of an accident at a level crossing [9].
This research characterises extraordinary events in
railway transport and the categorisation of accidents. Furthermore, it examines
the dependence of accidents on various circumstances of non-compliance. And
assesses a serious accident that has become as a collision on a railway
crossing.
2. THEORETICAL BACKGROUND OF THE
REASON MODEL APPLICATION
The Reason model (Swiss Cheese model) is a model showing
accidents with their causes. It was primarily developed for use in the aviation
sector. It is being used in other areas, such as risk analysis and risk
management, engineering, healthcare, and computer security as well. It compares
the systems and human management to several cheese slices stacked in a row.
Therefore, it is justifiable to make an attempt to formally describe specific
parts of cheese components, which are necessary for various types of analyses.
Such a description allows us to create models that may be more or less
developed. The risk that the threat becomes a reality is mitigated by these
layers with varying degrees of protection. Thus, if the threat begins to spread
through individual layers, it does not mean that it will result in an accident,
but that one of the layers will avert the spread of the threat [19].
Reason assumed that the causes of accidents are based on
one of four areas [25]:
·
organisational effects – training of drivers at
the lowest possible cost,
·
control – inexperience, lack of finesse,
·
assumptions – fatigue, communication failure,
·
concrete procedure – non-compliance, excessive
compliance.
In
this model, emergency protection monitors through the obstacles (protective
means) represented by the slice of cheese. The openings in the section
represent weaknesses in the different parts of the system and differ in size
and position across the sections. The system allows failure when the hole in
each plate momentarily aligns, allowing an accident trajectory. Danger passes
through holes in all sections, leading to failure [25].
According
to its international background in transport cases, the model includes active
errors and latent errors.
While
active errors are obvious and can occur suddenly for various causes, latent
errors are characterised by their latency. At a certain period, the error may
not be visible and may then be reflected. Tab. 1 gives examples of errors.
Tab. 1
Examples
of errors that occur in the Reason model
|
Active errors |
Latent errors |
|
ETCS failure |
cracks on the vehicle |
|
burning a light bulb on a signal |
bomb on board |
|
dispatcher error |
virus spread |
Every undertaking has directives and individual
procedures, the application of which seeks to avoid mistakes and prevent
accidents. Fig. 1 is a graphical illustration of the Reason model.
Fig. 1. Emmental Swiss cheese model [25]
From
the figure, it is clear that passing the red arrow through all the holes will
cause an extraordinary event. Unless it passes through all the holes, there
will be no extraordinary event.
3. CLASSIFICATION
OF EXTRAORDINARY EVENTS IN RAILWAY TRANSPORT
The
railway sector is known for its strict approach to safety. Under the conditions
of the infrastructure manager (entity managing the railway infrastructure) of
the Slovak Railways (hereinafter referred to as ŽSR), the Department of
Safety and Inspection was established.
Amendment to
the Act on Railways 513/2009 Coll. instructed the railway operators and
carriers (railway undertakings) to issue an internal regulation containing [15]:
- procedures for identifying the causes of
an accident and an incident;
- a detailed categorisation of accidents and
incidents,
- the method of reporting accidents and
incidents,
·
the roles of organisational units of the railway
operator and carriers involved in the identification of the causes of accidents
and incidents.
These
and other obligations resulting from the abovementioned Act and Decree 250/1997
Coll. are in the ŽSR conditions elaborated in the regulation “From
17 Accidents and extraordinary events”. This regulation was effective
from 1 January 2011 [16].
According to
this regulation, were defined [6]:
- extraordinary circumstance - is a sudden
event or chain of such events that originate in the operation of rail
infrastructure and rail transport, but which have the same consequences as
accidents (road wash, lightning strike, violent damage to infrastructure
equipment...),
- accident - is a serious accident, a minor
accident and an incident involving a moving railway vehicle with the
consequences of death, injury, danger to life and health of persons,
- incident - is an event that adversely
affects the safety and fluidity of rail traffic, it can be an unforeseen
event or an undesirable event,
·
operational failure - is an incident that is not
subject to the legal provisions of the Slovak Republic (hereinafter the Slovak
Republic) and the European Union (EU) on the registration, reporting,
investigation and statistical processing.
Tab.
2 categorises the different types of incidents according to Regulation Z 17
with examples of incidents.
Tab.
2
Categorisation
of accidents
|
Category of accident |
Consequences |
Examples |
|
A – Serious
accidents |
fatal injury |
train crash |
|
severe injury to at least 5 persons |
derailment of the train |
|
|
widespread damage to railway vehicles |
collision of a railway vehicle with users of the
crossing |
|
|
extensive damage to the railway infrastructure |
fire of a railway vehicle |
|
|
extensive environmental damage |
personal injury caused by the movement of a railway
vehicle |
|
|
extensive damage to the property of third parties |
||
|
interruption of traffic on the 1. category of lines
for 6 hours or more |
||
|
B – Minor
accidents |
severe injury of up to 4 persons |
train crash |
|
damage to railway vehicles and railway
infrastructure |
derailment of the train |
|
|
damage to the environment and property of third
parties to the extent of greater damage of at least € 2,600 |
collision of a railway vehicle with users of the
crossing |
|
|
fire of a railway vehicle |
||
|
personal injury caused by the
movement of a railway vehicle |
||
|
C – Incidents |
minor damage |
quarry rails |
|
track deformation |
||
|
signalling error |
||
|
passing the signal STOP |
||
|
wheel and axle fractures |
As
operational failures are not serious enough to be considered subject to the
legal provisions of the Slovak Republic and the EU, it will not be dealt with
further. The investigation of individual incidents is an indispensable
document, the Accidents "Cover". It is a summary of the prescribed
aids, documents and forms needed to identify causes and report accidents and
incidents on the railway [16].
The
steps of determining the causes of accidents can be described in a simplified
way as follows [4]:
·
inspection of the scene of the accident and creation of a
record of the inspection,
·
collection of documentation and records;
·
measurement at the scene of an accident - commission
inspections and records;
·
writing notes with employees;
·
finding damage,
·
preparation of documentation,
·
determining the causes and responsibilities for the
occurrence of an accident,
·
closure of an accident.
For comparison purposes, an accident graph is
presented in Fig. 2 showing the cases of category A-C incidents in 2014-2019.
Fig. 2. Development
of extraordinary events on ŽSR network
The chart shows that year-on-year, compared to 2018, there was a
decrease in serious accidents (by 10), minor accidents (by 17) and incidents
(by 24) in 2019. One of the reasons for this is the ever-increasing provision
of train movements in the intermediate sections. Besides, the infrastructure
manager (ŽSR) is particularly concerned with preventing the occurrence of
extraordinary events [27].
4.
DEPENDENCE OF ACCIDENTS ON DIFFERENT CIRCUMSTANCES
The most common accidents include a collision
between a train and a road motor vehicle on a railway crossing. We classify
such types of accidents on the ŽSR network in category B.
The emergence of such accidents has several causes, for example:
·
driver inattention,
·
not respecting light
signalling,
·
vehicle breakdown directly
at the railway crossing.
Tab. 3 shows the individual values of the number of accidents
at railway crossings and the number of locomotives destroyed in 2017.
Tab. 3
Data to create a graph of linear dependence
|
Month |
Number of railway crossing accidents |
Number of locomotives destroyed |
|
1/2017 |
10 |
7 |
|
2/2017 |
3 |
3 |
|
3/2017 |
2 |
2 |
|
4/2017 |
6 |
2 |
|
5/2017 |
3 |
2 |
|
6/2017 |
5 |
4 |
|
7/2017 |
3 |
1 |
|
8/2017 |
4 |
2 |
|
9/2017 |
3 |
1 |
|
10/2017 |
1 |
1 |
|
11/2017 |
2 |
1 |
|
12/2017 |
8 |
5 |
The most accidents were in January, while the least
accidents were in October. Damage to locomotives likewise corresponds to this
condition. Using the Fisher test, the following table will determine the
dependence between the monitored indicators. Tab. 4 shows the individual
variables.
Tab. 4
Variables used to determine dependency
|
Variable |
Value |
|
R2 |
0,79 |
|
k |
1 |
|
n |
12 |
|
n-(k+1) |
10 |
|
F |
37,39 |
|
FTAB |
4,97 |
where:
·
R - reliability equation,
·
k - coefficient,
·
n - number of measurements,
·
F - calculated Fischer test
value,
·
FTAB - table
value of the Fischer test.
The Fischer value is calculated by relation 1. If
the calculated test value is higher than the table value, there is a dependence
between the monitored indicators.
(1)
Fig. 3 shows the graph of correlation between
selected factors that influence accidents at railway crossings.
Fig. 3. Graph of linear dependence between the number
of accidents on the level crossings and the number of locomotive damages
There is a dependence between the number of
accidents at the railway crossings and the number of damaged locomotives as
seen in Tab. 4. Other dependencies could similarly be detected in this manner.
For example, the dependence between the number of passengers and the number of
deaths on railway crossings or the dependence between the amount of delay and
the number of accidents on railway crossings. These circumstances are the direction
of the next research.
5.
APPLICATION OF REASON MODEL FOR RAIL ACCIDENTS – A CASE STUDY
Although this model was originally set in the air
transport environment, its application is possible in other modes of transport.
The article will analyse the accident of category A3, which happened on
February 21 at the unprotected railway crossing in Polomka.
Basic data [6]:
·
date and time of the
incident: 21. 2. o 9:04,
·
place of accident:
unprotected railway crossing at km 17.938 km in the Heľpa - Polomka
interstate section,
·
train type: Os 7353
(Červená Skala - Banská Bystrica),
·
type of road motor
vehicle: Bus Karosa LC 736.
Course of the accident [3]:
·
the train driver in
the direction Závadka nad Hronom - Polomka noticed that the incoming bus
does not stop in front of the crossing and is entering the crossing,
·
the driver had applied
fast-acting braking from a distance of 72 metres before crossing at 70 km per
hour,
·
despite the measures,
the passenger train crashed into the left centre of the bus,
·
the bus overturned to
the right side and the motor car derailed,
- The driver of
the bus has been identified as the main culprit, since the road safety
device was functioning correctly at the time of the accident.
Fig. 4 shows the number of people killed and injured
in this accident.
Fig. 4. Number of deaths and injuries [4]
Most people were injured lightly (19 in total) and 6
people were seriously injured. Unfortunately, up to 12 people suffered
life-incompatible injuries. This accident was described as the most tragic in
the history of ŽSR. The application of the Reason model is shown in Fig. 5
by a flowchart.
In the sense of the Reason's model, the accident
involved 3 slices of cheese. Tab. 5 shows the structure of penetration through
cheese holes.
Tab. 5
Penetrating through the holes in the cheese
|
Slice of cheese |
Circumstance |
Possibility of turning away |
|
1 |
the driver entered the
crossing despite the warning |
respecting the alert |
|
2 |
the train was coming |
train failure before crossing |
|
crossing test |
||
|
3 |
applying the handbrake by
the driver |
train stop |
Penetration through the slices in the cheese
resulted in an accident. However, if even one penetration did not get an
accident, it would not happen. Fig. 6 shows a photograph of the accident site.
The investigation for ŽSR was closed on 20
March 2009. Subsequently, the bus driver was accused because he did not respect
the crossing prohibition despite the correct functionality of the roadside
interlocking device.
Fig. 5. Flowchart of causes and consequences of an
accident
Fig. 6. Place of the accident [17]
6. CONCLUSION
Research poses a
likely risk that could lead to their occurrence at railway crossings. It is an
open issue, especially, necessary to deal with it. As much as future technical
solutions contribute, research finds that human potential is the greatest. According to
Gadek-Hawlena, human´s knowledge
about the correct behaviour in different situations, both the everyday ones and
the ones being a consequence of collisions or traffic accidents, is very
important. It is proven that even on fully
secured railway crossings there are many accidents caused by irresponsible
human behaviour. The most common failures in almost any activity are human
failures. The advancement of science and technology has therefore replaced
human labour with automated work in several areas of human life. However, there
are still areas where human work is indispensable and irreplaceable, despite
the progress being made.
The use of the Reason
model is versatile. It can be stated that the aim of this research was
fulfilled. This model is also applicable to railway transport. It shows the
circumstances that have occurred and caused the accident, and also shows the
threshold where an impending emergency can be averted and where it cannot. In
the future, it is possible to examine in this way other circumstances and
effects of risks at railway crossings. Research gives room for further progress
in this current and serious issue.
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Received 15.07.2020; accepted in revised form 22.10.2020
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