This chapter presents the results of a cognitive systems engineering approach applied to railway systems. This application is through the methodology of System for Investigation of Railway Interfaces -SIRI . The utility of the chapter lies in highlighting errors in the current approaches to safety risk management.
This paper presents the results of analysis of the Herefordshire level crossing accident using MORT method. The aim of the study is to produce a comprehensive list of accident causal factors as per the MORT method using the RAIB Report as the input document. MORT aids learning lessons after the event is a fact established in the safety literature [6].The MORT desk top study included collection of information and data that is publicly available to represent all relevant viewpoints to ensure completeness including authors previous work published in 2006 and 2010[2]. The MORT study revealed oversights and omissions that have occurred to cause the undesired accident. All RAIB, ORR and RSSB reports cited in the MORT study are available freely on the respective websites. Given the nature of the study, the SA2 branch of the MORT tree was excluded from the scope of the study.
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