| Popis: |
Railway occurrences in South Africa remain high, despite occurrence investigations conducted by the various organisations. A failure to thoroughly investigate the underlying causes for incidents may be a possible reason for the number of recurrences. A systems analysis of the South African railway industry illustrates the systemic factors within the railway system that influences the effectiveness of the occurrence investigation process. Systemic factors refer to challenges, pressures, frustrations or obstacles that contribute to the complexity of railway accident investigations. Rasmussen’s (1997) Risk Management Framework was operationalised for the South African railway system. A qualitative multi-method approach was adopted in this research. Methods included a print media analysis of 133 reported railway accidents, governance document analyses, 23 semi-structured interviews with railway investigators, 4 observations during actual inquiries and analyses of railway occurrence reports. The data were compared and verified against each other using triangulation. An Accimap was used to graphically illustrate the complexity of the investigation process. This systems analysis tool highlights that the system of accident investigations is indeed a complex system in its own right, and not just the rail accidents themselves. The rail investigation system in South Africa can be described as a broken ‘system of systems’. Deficiencies and complexities in the system of accident investigations limits the effectiveness of the entire investigation process from achieving its objectives - that is to learn from such events - offering an explanation for why railway safety trends remain unchanged in South Africa. |
