Improving signal passed at danger management in New Zealand rail operations: Combining stabilised approach procedures with risk-triggered commentary driving

Abstract

The critical examination of driver cognition and information processing is vital to ensuring an effective signal passed at danger (SPAD) prevention strategy. Although this need was identified in KiwiRail's organisational strategy to reduce signal passed at danger risk, the why and how factors were not clearly described and robustly linked to deliver the necessary effects. With risk-triggered commentary driving programmes gaining recognition as valuable components and activities within the driver competency model, an opportunity to couple risk-triggered commentary driving with stabilised approach methodologies and procedures, adopted from aviation and modified for use on New Zealand's railway network was subsequently identified. A driver subject matter expert group was formed, a literature review completed, guidance developed and new procedures trialled. This activity provided new opportunities to introduce error-tolerant system design, increase accuracy of driver signal action response and reduce signal passed at danger risk on New Zealand's National Rail System by adopting and designing bespoke methodologies that support enhanced driver cognition and safe system design.

Utilisation of ‘verbalisation’ to reduce the complications of tracheal intubation

“…In addition, if the operator is part of a team it allows the coworkers to know that the task has been satisfactorily completed. Consequently, it is used extensively by the airline and rail industries to reduce human error and is especially recommended for single pilots . Therefore, we propose that all of the aforementioned pre‐intubation checklists could, and should, be improved by the addition of a further five standardised statements to be verbalised during and immediately after tracheal intubation in order to ensure safe placement of the tracheal tube and to reduce the occurrence of induction‐related AAGA.…”

“…These parturients represent a high-risk group as maternal hyperglycaemia is associated with an increased incidence of miscarriage, sepsis and pre-eclampsia and, as gestational diabetes is associated with obesity and increased maternal age, they are at further risk of complications [2].…”

“…In 2015, in an effort to improve outcomes for both infant and mother, the National Institute for Health and Care Excellence (NICE) published clinical guidance on 'Diabetes in pregnancy: management from preconception to the postnatal period' [2]. Among other recommendations, the guidance recommended that capillary blood glucose should be maintained between 4 mmol.l À1 and 7 mmol.l À1 during delivery, and that intravenous (i.v.)…”

“…As well as written checklists and aviation-style checklists, verbalisation of important steps (also known as risk-triggered commentary) has been demonstrated to reduce human error when complex tasks are performed [2]. The act of verbalisation facilitates the cognitive control processes that are necessary for effective retrieval and activation of working memory to be reinforced.…”

“…In addition, if the operator is part of a team it allows the coworkers to know that the task has been satisfactorily completed. Consequently, it is used extensively by the airline and rail industries to reduce human error [2,3] and is especially recommended for single pilots [3].…”