Event recorders, often referred to as 'black boxes', have been common in the aviation and rail sectors for many years. These devices record critical actions of the operator (pilot or driver) as well as information about the vehicle such as speed and acceleration rates. Event recorders are mainly known for their use in reconstructing the events before a serious accident, but they can also be used proactively to unobtrusively monitor an operator's performance. Used in this way they can provide an opportunity to develop competence or change behaviour before an undesirable event occurs. We make use of event recorders in both competence management systems and during accident investigations for rail and tram clients.
Now, a surgeon in Toronto is pioneering the use of these devices in surgery to help identify problems in preparation for surgery, and as a tool to investigate problems after they have happened. Read the full news story on the Toronto City News website.

When a driver left his tram to investigate a problem with the power supply, an unfortunate error led to considerable damage. The driver had left the tram in 'on' mode, so when the power problem disappeared the now driverless tram set off on its own. To see the full story, read the story on the Rush Lane and the Times of India's websites.
Eliminating the potential for errors like this is normally common practice, but much of Calcutta's tram system is now very old. Nevertheless, this accident should raise concerns about many human factors issues including task design, training and competence and procedural controls as well as risk management. 

It's been a bad week in the news for the UK's military. Two human-related mishaps during training exercises could have had serious consequences. In the first incident, on Salisbury Plain, a 105mm round was fired towards the safe test firing area but because the wrong charge was used it went "much further" - 5 miles further. It exploded in a farmer's field, just 300m short of the main railway line. See the news story on the BBC website.
In the second incident, a torpedo was accidentally launched from HMS Argyll inside Devonport naval base. The torpedo was an unarmed version used for testing drills, so did not explode when it impacted a safety fence. See the news story here.
In both cases, the investigations have been launched to try to understand the causal factors.


See our pages on incident investigation and common causes of human error to see how we are helping organisations manage the 'human factor' in their business.

A fallen power cable caused a wildfire in the US state of Washington. Electrical power company engineers attending the incident believed that the other end of the power cable was also disconnected at the top of a pylon and so posed no danger to firefighters on the ground. However, the power cable was still live at 7.2kV and when a volunteer firefighter used a portable fire extinguisher on the fire he received an electric shock. Fortunately the firefighter was unharmed. For the full news story, see the Tri-City Herald report.

See our pages on procedures and documents, risk management and accident investigation for information about managing risk in an operational environment.

In March 2013 seven US Marines were killed when a Marine double-loaded a 60mm mortar on a training exercise. Eight other Marines were injured by the explosion.
The investigation concluded that several common 'human factors' led to the accident: 

• inadequate training and preparation;
  
• communication (firing commands);
  
• procedures; 
  
• supervision, and;
  
• task workload. 
  

See the full news story on the USA Today website.

Fortunately, in industry the outcome of human error is rarely this significant. For details on how we can help identify and manage human factor risks in industry, see our consultancy pages.

A Metro-North train derailed in the Bronx on December 1st 2013, killing four people and injuring more than 70. The train had entered a curve at nearly 3 times the permitted speed. Recent investigations appear to show that overtime working is endemic on the railroad; the driver in the crash had worked the equivalent of a six-day week every week for the past three years.
See the full news article on the NBC website.
In the UK, fatigue of safety critical workers must be managed; the Office of Rail and Road has issued guidance on the risks of excessive working hours and how these can be managed (see here).
For details on how we can help identify and manage human factor risks in industry, see our consultancy pages.

A collision on the new Metrolink Oldham town centre line has sparked calls for layout changes at a busy roundabout.
See the news report in the Oldham News for more details.

ON Christmas Eve 1874, Oxfordshire witnessed its worst ever railway disaster when a train derailed at Shipton-on-Cherwell, killing 34 passengers. 69 other people were seriously injured. The basic cause was found to be a broken tyre on the carriage just behind the locomotive, but that failure was worsened by the poor braking system fitted to the train.

The report can be found here on the Railways Archive.

On the 12th December 1988 a crowded passenger train crashed into the rear of another train that had stopped at a signal, and an empty train, travelling in the other direction, crashed into the debris. Thirty-five people died and nearly five hundred were injured.
The primary cause of the crash was incorrect wiring work on the signalling system; a redundant wire was left connected at one end, and bare at the other. The wire came into contact with a relay, causing a signal to display a 'wrong side' green aspect regardless of the presence of a train on the track circuit. The signalling technician responsible had also worked a seven day week for the previous thirteen weeks.
Twenty five years on from the Clapham Junction rail disaster, a survivor is still remembering fresh details from that harrowing day.

See the news item here, and the accident report on the Railways Archive website here.

WASHINGTON -- The NTSB continues to rule out mechanical causes in a deadly Bronx train crash while adding to the possibility that human error was involved. Federal safety investigators have all but eliminated mechanical problems as the cause of the December 1 derailment, but there are indications that the driver might not have been as attentive as he should have been.
See the news item here and the NTSB's page on this accident here.