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• W2127834294 abstract "Analysis tools that help us learn more effectively from past incidents and accidents will assist further improvements in rail safety. This study assesses the ability of CREAM (Hollnagel, 1998) to expose limitations in the system of human and organizational factors surrounding hazardous incidents occurring as driver approach signals. To identify suitable signal incidents for analysis, 115 train drivers were asked on two separate occasions about their involvement in incidents in the preceding 4 months. Ten interviews with drivers involved in signal approach incidents were analyzed using CREAM, resulting in a unique antecedent event chart for each case. Systematical aggregation of these charts revealed three common explanations for hazardous incidents in which the driver misses a signal: inattention, an inappropriate schema, and lack of signal salience. Routine exposure to invariant signal aspects was suggested as a precursor of inattention, and may also be linked to the development of inappropriate schemas that drivers fall back on in unusual or demanding situations. We suggest that organizations challenge the formation of inappropriate schemas by drivers exposed to extreme routine. As far as these findings are useful, CREAM is an effective method for revealing the psychological and sociotechnical processes preceding hazardous rail incidents. It should be further optimized for use in the analysis of rail incidents." @default.
• W2127834294 created "2016-06-24" @default.
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• W2127834294 date "2014-07-01" @default.
• W2127834294 modified "2023-10-09" @default.
• W2127834294 title "What did you expect? CREAM analysis of hazardous incidents occurring on approach to rail signals" @default.
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• W2127834294 doi "https://doi.org/10.1016/j.ssci.2014.02.003" @default.
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