ABSTRACT

Incident investigations are a key source of information on how human error, system design and organizational factors impact on risk. In the UK context there has not previously existed a database which draws together the different factors across a range of incident types to look at patterns and trends in these data. This work has been undertaken by theRSSBHF teamwith input fromHuman Factors/Ergonomics specialists from Network Rail and the Office of the Rail Regulator. The aim of the project was to base the approach on existing classifications of human error with some pedigree, rather than trying to invent new classifications. The analysis therefore began with the TRACEr classification methodology (Shorrock, 2006) and developments of the approach by Nottingham University in the context of the rail industry (e.g. RSSB, 2004). Using these classifications, the basic methodology which was applied can be summarized in the following steps:

1. Development of a database to support the classification and storage of data. The relational database was developed in-house such that the

database could be adapted based on user feedback and developments in the approach.