Task $4$: Human factors $($HSG$48)$

$4$

$($a$)$ Leading up to the train crash, the on$-$site supervisor and Engineer D committed health and safety violations.

Identify the situational violations made by EACH of these individuals.

$(4)$

Note: Your answer must be based on the scenario only.

$($b$)$ What organisational factors at Contritum could have contributed to the train crash?

$(8)$

Note: Your answer must be based on the scenario only.

$($c$)$ What individual factors of Engineer D could have contributed to the train crash?

$(5)$

Note: Your answer must be based on the scenario only.

Engineer D

Once on site, Engineer D can see the lights of the large train station only $200$ metres away. They confirm that the track is closed to trains. The on$-$site supervisor explains to Engineer D what needs to be done first in the signal box. All the wires to the relays on the lower shelves need to be replaced with the new wire. This will then be fed out through a duct to the signals and points along the track. Having explained this, the supervisor then takes the other three engineers to the various locations where the rest of the night$$s work needs to be completed.

Engineer D enters the signal box and finds that the lights do not work. Undeterred, they wear a head torch to carry out the work. However, in the tight spaces behind the relays, they find that the head torch becomes restrictive. Although the rule is to always wear a head torch during night work, they decide to take off the head torch and use it as a hand torch. While working, Engineer D hears shouting and laughing nearby; in the distance they hear a police siren. Even though they are in the middle of rewiring, they go outside to see what is happening.

In the dim light they see someone climb through the broken fence towards the railway. They are clearly not wearing any reflective clothing. The person trips on the railway tracks, falls to the ground, and yells out in pain. Engineer D moves towards the injured person to help, and notices two police officers approaching. The police determine that the injured person has broken their ankle. The police arrest the person and call for an ambulance.

Engineer D speaks to the police and helps guide the paramedics to the injured person. An hour later, Engineer D returns to their work, upset by the event. They are now behind schedule with their work so they try to catch up$.$ Despite the delay, cramped conditions, and accumulated dust everywhere in the signal box, Engineer D finishes all the rewiring on time. They are glad to finish work for the week and are looking forward to a day off. The on$-$site supervisor enters the signal box and asks if everything has been done. Engineer D explains about the earlier interruption and the on$-$site supervisor remarks, $$Oh$,$ people are always getting on to the railway tracks. I will have to report it again.$$ The on$-$site supervisor accepts Engineer D$$s assurance that everything has been completed. They decide not to check the work because the railway lines are due to be open again soon.

The train crash

At $06$:$10,$ an early morning train approaches the signal box, where the work had been completed the night before. The train stops as the signal is set to red. At $06$:$12,$ a second train crashes into the stationary one ahead of it$.$ Some carriages derail and the stationary train is shunted $50$ metres along the track. The TrainDetect system has failed to alert the signalling centre or the train drivers that the trains are too close to each other on the same track.

The station workers see the dust rising from the crash site and immediately call the emergency services. Many people are injured on both trains.

On investigation, the TrainDetect system failure is traced back to one of the old wires that should have been removed by Engineer D$.$ The wire was not bent back on itself and insulated, as per the job specification, causing a fault in the TrainDetect system.