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Learning from Accidents, 3rd edition, 2001-09

作者:
Trevor A. Kletz
ISBN :
9780750648837
出版日期:
2001-09-12 00:00:00
语言:
国家地区:
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262Learning from Accidentsthe driver was charged with manslaughter but the prosecution offered no evidence and he was acquitted. The railway company was prosecuted and fined. This brief survey of SPADs shows that: ��the police and the prosecutions service did not seem to learn from experience which prosecutions were unlikely to succeed. the police and the prosecution service seemed unable to realise that no driver, except a suicidal maniac, would knowingly drive into the train in front. They did not realise that everyone has unavoidable lapses of attention from time to time which cannot be prevented by threats of punishment or by telling people to be more careful and that therefore we should look at ways of reducing SPADs by modifying tracks, signals and trains. Blaming uman error�diverted attention from what could be done by better engineering. juries showed more understanding of human nature than the police.�I have written in the past tense as these attitudes seem to be changing (see the quotation at the beginning of this Chapter). The report on the Southall accident6,7 recommended that an expert body such as the Railway Inspectorate, not the police, should in future direct investigations into railway accidents (unless terrorism or vandalism are suspected).23.2Reducing SPADS by better engineering etc.In some cases we could improve visibility. About two-thirds of SPADS occur at signals where they have occurred before8, thus indicating that these signals are probably more accident-prone than the drivers. At Purley, for example, as just described, visibility was poor. In other cases signals have been confused with other signals. (Similarly, an ccident Spotlight�issued by a police force gave a diagram of a road junction where seven accidents had occurred in the past year and then said, rincipal cause; road user error� People can be so blinded by their preconceptions that they cannot see the obvious.) In some places there are so many signals that a driver may read the wrong one. If the following signal is visible and green the driver may ead through�and see only that one. A risk assessment now has to be carried out when several SPADS have occurred at the same location and changes made if it is reasonably practicable to do so. Most SPADs, over 99%, do not result in accidents9. When one train is following another down a line the first train is usually well ahead. SPADs are most likely to result in an accident when there is a conflicting movement, that is, one train has to cross the path of another10. Such movements are inevitable at junctions, unless one line is bridged over
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