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IMPROVING INCIDENT ANALYSIS IN THE DUTCH RAILWAY SECTOR

This study set out to examine whether a comprehensive analysis technique for analysing incidents and accidents would provide greater insight in the underlying root-causes of SPAD's. In order to examine whether the current approach to incident analysis provided a sufficiently detailed analysis of the underlying root causes of SPAD's a comparative analysis using PRISMA was performed. The results of the analysis demonstrate that despite the fact there was no significant difference in the numbers of root-causes identified in the re-analysis of the same incident data, there were significant differences in the types of root-causes identified. PRISMA identified significantly more technical and organisational causes and significantly less staff-related root causes. Furthermore, this study revealed that not all information appeared to be used in the analysis, a fact supported by the provisional results of a third analysis where PRISMA was used to collect new information on the causes of very recent incidents. As such, it may be concluded that only when an organisation applies a comprehensive approach to data collection and analysis, will it be possible to state that the real root causes of an incident have been determined.