![]() ![]() A qualitative cross-sectional multiple-case design was used to categorise a large dataset comprising completed SPAD pro formas (n = 208) from 10 rail organisations across Australasia. pro forma) investigators use to capture information and attribute SPAD causation, in order to determine the extent which systems thinking is reflected in the information captured. The aim of this study was to examine the document (i.e. One area overlooked in SPAD research is the investigation process itself, specifically in terms of what investigators do and do not look at when investigating incidents. ![]() In the context of rail, Signal Passed at Danger (SPAD) incidents are a weak link in an otherwise safe system and one of the few points where a single failure can have catastrophic consequences. Through systems thinking it is recognised that human error is not a matter of personal control, but an emergent property of overall system design.
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