In case of emergency press button B … or is it C?

Real consequences for real people

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Let’s find the broken bits ..

Radio active in trailing locomotive Driver didn’t log on Train controller didn’t register train New train controller registered trailing loco No communication with driver to register Train controller didn’t make broadcast call Train controller didn’t have phone numbers Incident was not given priority Repeat of similar incidents.

Everyone wanted to work safely.

None of them did.

The entire system had drifted.Drifted into failure.

Mobile phones

A great convenience, or a lethal distraction?

Mobile phones

They are a part of life for virtually everyone.

Mobile phones

Do we ban them, or embrace them?

Mobile phones

Or both?

Mobile phones

Or both?

Mobile phones

In Japan they have been used since 2004

Mobile phones

In other countries they are banned …

Mobile phones

except when it is convenient for the railway.

Mobile phones

We have changed.

Mobile phones

We cannot hold back the tide.Embrace the change and make it safe!

What is different?

Traditional Two Way Radio Personal Communication Device

Formal Informal

Structured Spontaneous

Open Channel – everyone hears Closed Channel

Situation awareness for all Just the two of us

Independent check of accuracy Credibility

Monitored, recorded May not be monitored or recorded

Press to talk Find number, dial, wait to connect

Anyone can answer Presumption of correct connection

Static configuration Numbers change without notice

Mobile phones

This could be dangerous!

Incident Situation

Pakenham Train radio failed, cellular only medium.

Lavington Train radio no coverage, cellular only medium.

Waterfall Crew disabled. Passenger phoned 000.

Leigh Creek Sat and cellular damaged.

Guelph Cellular privacy used to cover error, created hazard.

Grawlin Plains Incident report by phone, numbers not given.

Asta Imminent collision, numbers not known

Knowledge and error flow from the same mental sources, only success can tell one from another.Ernst Mach, 1905

Strathfield

Homebush

Summit Tunnel

Lewes

Hexham

Recommendations for Success

• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.

Recommendations for Success

• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.

Recommendations for Success

• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.

Recommendations for Success

• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.

Recommendations for Success

• Train in realistic situations• Use simulators• Test a range of scenarios• Practice until it is natural• Assess regularly.

Recommendations for Success

In case of emergency, press button “A”