From Nobel Prizes to Safety Risk Management: How to Identify Latent Failure Conditions in Risk Management Practices

Abstract

The aim of the Chapter is to introduce readers to the Cognitive Biases found in Railway Transport Planning and Management domain. Cognitive biases in planning of railway projects lead to cost overruns, fail to achieve performance and fulfil safety objectives as well is noted in the economics, business management and risk management literature as well. Unbiased decision making is a core goal of systems engineering, encouraging careful consideration of stakeholder needs, design alternatives, and programmatic constraints and risks. However, Systems engineering practices dealing with Railway Transport Planning and Management fields do not pay attention to the human factors and organisational factors at initial stages of planning where driveability of European Railway Traffic Management System (ERTMS) Trains emerges as a concern in real time operations is noted in the Railway Transport Planning and Management domain. Therefore, there is a case for studying the Cognitive Biases in this domain. The System for Investigation of Railways (SIRI) Cybernetic Risk Model (2006), (2017) is a Systems engineering response to the internal research brief by RSSB, a GB Railways Safety Body. The SIRI Cybernetic Risk Model (2017) incorporating the “Heuristics and Biases” approach was published by the UK Transport Select Commission as a Written Evidence in 2016 on the occasion of the Inquiry theme of Railway Safety. The validity of the SIRI Risk Model (Swiss Cheese Model) is further illustrated through the 2019 historical survey of railway accidents and the two recent RAIB investigations of track worker fatal accident and signalling related near miss event in the form of Swiss Cheese Model. The data and information in the RAIB Reports (17/2019) and (11/2020) is supplemented by further research and the author’s own past studies of accident analyses. The results of the study show that the Guide to Railway Investment Process (GRIP) (2019) (now deleted by Network Rail) has no provision for incorporating measures to address to deficiencies raised by the accident reports or safety analysis reports as the RSSB (2014) Taking Safe Decisions Framework does not include all Hueristics and the biases they lead in the information used for taking decisions. Thus, the Duty Holder Investment process fails to meet the requirements of the mandatory regulatory requirements of the Common Safety Method-Risk Assessment (CSM-RA) Process. The results of the Case Studies in the Chapter remain the same despite the proposed changes in the Shapps-Williams Reform Plan (2021) as the safety related matters are not yet addressed by the plan. The author hopes when the lessons that are learnt from the Case Studies are embedded in railway organisations then we may see improvements in the railway planning and management practices by considering the risk factors at the conceptual stage of the projects and meet the requirements of ISO Standard 27500 (2016) for Human Centred Organisation. National Investigations Bodies (NIB) also may be benefitted.