The railway is becoming ever more complex – organisationally and technically – with a greater range of people and backgrounds working all together. System safety is key and learning from incidents plays a key part in enabling the industry to introduce improved risk controls.
In October 2017 a software-related incident occurred on the Cambrian line that was subsequently investigated by the Rail Accident Investigation Branch (RAIB). The investigation highlighted the importance of taking a systems safety view throughout the project lifecycle.
Cambrian Incident
A short summary of the Cambrian incident, including the immediate cause of the incident, the causal factors, and an analysis of when the causal factors occurred during the project lifecycle, can be found here. RAIB Cambrian – summary of investigation findings
For an overview, listen to this short RSSB podcast here.
The full RAIB report on the Cambrian incident available here.
Recommendations
In response to the RAIB Cambrian recommendations, this webpage has been produced to “support the wider rail industry with improved capture and dissemination of safety learning through the reporting and systematic investigation of complex software-based system failures”. Relevant case studies are available to view on the right hand side of this page.
RSSB have also produced some short podcasts (15-17 minutes long) and blogs (2-3 minutes read) which support increased integration of complex software-based systems within the rail network system. Available here
Case Studies
Case studies of non-software-based complex accidents with organisational factors relevant to system safety are included and regularly updated on RSSB learning from other sectors page.