摘要: |
The aim of this study was to identify accident precursors that are theoretically sound and reasonably practical to implement at an operational and management level. This study: 1) Identified accident precursors and constructed generic fault trees to display graphically the accident precursors for six key accident types. 2) Gained insight into the accident precursors reported and monitored at NSA, IM and RU level across member states, to understand current practice and the motivations behind it. 3) Identified a harmonised set of accident precursors that might be used for safety management at EU, NSA, RU and IM levels, by combining the theoretical accident precursor fault trees and the actual, practical understanding of accident precursor reporting and monitoring. It may be informative for NSAs, RUs and IMs to consider precursors identified as being large contributors to risk, and precursors gathered by other NSAs, RUs and IMs. Provisional definitions for high risk precursors are suggested. The careful selection of CSIs is critical to ensuring that they do not distort performance or detract from other activities that contribute to improving safety. When considering how precursors might be used, a clearer distinction might be required between precursors used for regulatory purposes and precursors used for safety management purposes. To facilitate precursor monitoring and increase its value, there is a need to ensure that there is a good ‘safety culture’ across the rail industry. The use of precursors for operational reasons is vital to the proactive management of safety. Railway stakeholders across Europe are keen to share best practice with each other in this field, and ERA should make the most of this by continuing to work constructively and appropriately with stakeholders to develop a more harmonised European railway system. |