Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 32716
Case Study Analysis of 2017 European Railway Traffic Management Incident: The Application of System for Investigation of Railway Interfaces Methodology

Authors: Sanjeev Kumar Appicharla


This paper presents the results of the modelling and analysis of the European Railway Traffic Management (ERTMS) safety critical incident to raise awareness of biases in systems engineering process on the Cambrian Railway in the UK using the RAIB 17/2019 as a primary input. The RAIB, the UK independent accident investigator, published the Report- RAIB 17/2019 giving the details of their investigation of the focal event in the form of immediate cause, causal factors and underlying factors and recommendations to prevent a repeat of the safety-critical incident on the Cambrian Line. The Systems for Investigation of Railway Interfaces (SIRI) is the Methodology used to model and analyse the safety-critical incident. The SIRI Methodology uses the Swiss Cheese Model to model the incident and identify latent failure conditions (potentially less than adequate conditions) by means of the Management Oversight and Risk Tree technique. The benefits of the SIRI Methodology are threefold: first is that it incorporates “Heuristics and Biases” approach, in the Management Oversight and Risk Tree technique to identify systematic errors. Civil engineering and programme management railway professionals are aware of role “optimism bias” plays in programme cost overruns and are aware of bow tie (fault and event tree) model-based safety risk modelling technique. However, the role of systematic errors due to “Heuristics and Biases” is not appreciated as yet. This overcomes the problems of omission of human and organisational factors from accident analysis. Second, the scope of the investigation includes all levels of the socio-technical system, including government, regulatory, railway safety bodies, duty holders, signalling firms and transport planners, and front-line staff such that lessons learned at the decision making and implementation level as well. Third, the author’s past accident case studies are supplemented with research pieces of evidence drawn from the practitioner’s and academic researchers’ publications as well. This is to discuss the role of system thinking to improve the decision making and risk management processes and practices in the IEC 15288 Systems Engineering standard, and in the industrial context such as the GB railways and Artificial Intelligence (AI) contexts as well.

Keywords: Accident analysis, AI algorithm internal audit, bounded rationality, Byzantine failures, heuristics and biases approach.

Procedia APA BibTeX Chicago EndNote Harvard JSON MLA RIS XML ISO 690 PDF Downloads 277


[1] RAIB, "Report 17/2019: Loss of safety critical signalling data on the Cambrian Coast line, 20 October 2017," 19th December 2019. (Online). Available: (Accessed 5th January 2020).
[2] S. Hall, The Railway Detectives: 150 year old saga of the Railway Inspectorate, London: Ian Allen, 1990.
[3] J Reason, Human Error, 17th ed., New York: Cambridge University Press, 1990.
[4] J. Reason; E. Hollangel; J Paires, "Revisiting the « Swiss Cheese » Model of Accidents," Eurocontrol Agency, BRUXELLES, 2006. (Online). Available: (Accessed 2011 September 2011).
[5] L. Lochman, "Background on ERTMS," in Compendium on ERTMS -European Rail Traffic System, 2009 ed., Hamburg, EUrail press, DVV Media House, Hamburg, 2009, pp. 31-50.
[6] P. Simon, ""Standardizing European Railways: A Supranational Struggle against Persistent National Languages and Emergent Local Dialects"," Flux, Vols. 79-80, no. 1, pp. 124-136, 2010.
[7] S. Appicharla, "Modelling and Analysis of Herefordshire Level Crossing Accident using Management Oversight and Risk Tree (MORT)," IEEE, 21st September 2011. (Online). Available: (Accessed 23rd January 2012).
[8] Oldfield, Professor Agi; Ltd, Anser Conspectus, "RSSB Report: T169 – Risk in Management Systems Rev 2," RSSB, London, 2004.
[9] I. M. Copi and C. Cohen, Introduction of Logic, Low Price Edition, 2001 ed., Delhi: Pearson Education, 1998.
[10] Nobel laureate, Prof Daniel Kahneman, Thinking Fast and Slow, London: Penguin Group, 2012.
[11] Nobel laureate, Sir Roger Penrose, The Road to Reality: A complete Guide to the Laws of Universe, 2004 ed., London: Jonathan Cape, 2004, p. 1049.
[12] The Noordwijk Risk Initiative Foundation; Royal Dutch Navy, "NRI MORT User’s Manual," 20 December 2009. (Online). Available: (Accessed 16th March 2017).
[13] The Office of Rail and Road (ORR), "Guide to ROGS: The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (as amended)," ORR, London, 2020. (Online). Available: (Accessed 23rd December 2020).
[14] S. K. Appicharla, "RSL 024 and RSL 013: Written Evidences for the UK Transport Select Committee’s Railway Safety Inquiry," 09th January 2017. (Online). Available: (Accessed 31st May 2020).
[15] Katja Schuitemaker; Heidi van Spaandonk; Marco Kuijsten; Mohammad Rajabalinejad, University of Twente (UT), Utrecht, the Netherlands (UN), "Evaluating Key Factors Influencing ERTMS Risk Assessment: A Reference Model," International Journal on Advances in Systems & Measurements, vol. 11, no. 1,2, pp. 22-35, 2018.
[16] Kathryn J. Mearns, Wood PLC, Aberdeen, UK, "Safety Leadership and Human and Organisational Factors (HOF)—Where Do We Go from Here?" in Human and Organisational Factors: Practices and Strategies for a Changing World, Toulouse, France, Springer Open, 2020, p. 138.
[17] Ryan, Brendan, the Nottingham University, ""Accounting for differing perspectives and values: the rail industry." In Human and Organisational Factors, Springer, Cham, 2020.," in Human and Organisational Factors, Practices and Strategies for a Changing World, Toulouse, France, Springer Briefs in Safety Management, 2020, pp. 5-13. (Online). Available: (Accessed 23rd August 2020).
[18] S. Appicharla, "System for Investigation of Railway Interfaces," in The Fifth IET International System Safety Conference, Manchester, 2010b. Online). Available: (Accessed 3rd August 2021).
[19] D. P. Winter, “Compendium on ERTMS”, Hamburg: DVV Media Group GmbH, 2009.
[20] UNISIG, "SUBSET-091: Safety Requirements for the Technical Interoperability of ETCS in Levels 1 & 2, version 3.4.0," UNISIG, Brussels, 2015. (Online). Available: (Accessed 30th March 2020).
[21] International Electrotechnical Commission Contributors, "Functional Safety and IEC 61508," 2010. (Online). Available: (Accessed 18th September 2019).
[22] RAIB, "Report 27/2009: Investigation into runaways of road-rail vehicles," October 2009. (Online). Available: (Accessed 3rd October 2019)
[23] BS ISO/IEC 15288: 2002, Annex D, System Concepts, London: International Electro-technical Commission /BSI London, 2002.
[24] P. N. Leveson, "A New Accident Model for Engineering Safer Systems," Safety Science, vol. 42, no. 4, pp. 237-230, 2004.
[25] Sir Peter Hendy, Chairman, Network Rail, "Report from Sir Peter Hendy to the Secretary of State for Transport on the replanning of Network Rail’s Investment Programme November 2015," Network Rail, London, 2015. (Online). Available: (Accessed 31st May 2021).
[26] Dr Sandra Gadd, Dr Deborah Keeley, Dr Helen Balmforth, Health & Safety Laboratory, "Good practice and pitfalls in risk assessment," HMSO, Norwich, 2003. (Online). Available: (Accessed 29th May 2021).
[27] J. Prof Anson and N. Barnatt, "Safety analysis in a modern railway setting," Safety Science, pp. 177-182, 2018. (Online). Available: (Accessed 25th August 2019).
[28] Technical Committee ISO/TC 262, Risk management., "ISO 31000(en) Risk management — Guidelines," February 2018. (Online). Available: (Accessed 15th April 2021).
[29] ORR, the Office of Rail and Road, "Risk Management Maturity Model (2019) Amended 2020," ORR, 2019. (Online). Available: (Accessed 9th July 2020).
[30] CLC/Tc 9X " Electrical and electronic applications for railways, "BS EN 50126 Part 1: Railway applications —The specification and demonstration of Reliability, Availability, Maintainability and Safety (RAMS)," 2020. (Online). Available: (Accessed 3rd August 2021).
[31] S Appicharla, “System for Investigation of Railway Interfaces,” US IEEE, 7th June 2006. (Online). Available: (Accessed 2015 December 2015).
[32] European Commission Fifth Framework programme, "D2.9.1: Synthesis of SAMRAIL findings," The European Commission, Brussels, 2006European Commission Fifth Framework programme, "D2.9.1: Synthesis of SAMRAIL findings," 2006. (Online). Available: (Accessed 24th April 2019).
[33] WS Atkins Rail Limited, UK, "European Commission Fifth Framework programme: SAMRAIL/SM/D2, D2.9.1: Synthesis of SAMRAIL findings," 8th December 2004. (Online). Available: (Accessed 11th February 2020).
[34] Kathleen Fox, MSc in Human Factors and System Safety, Lund University, Sweden, How has the implementation of Safety Management Systems (SMS) in the transportation industry impacted on risk management and decision-making? Lund, Scania, Lund University, Sweden, 2009. (Online). Available: (Accessed 29th May 2021).
[35] Simon French, Chief Inspector of Rail Accidents, Tabitha Steel, Human Factors Specialist, Rail Accident Investigation Branch, United Kingdom, "Discussion paper 20: The Investigation of Safety Management Systems and Safety Culture:" in The Roundtable on Safety Management Systems, Paris Cedex 16, 2017. (Online). Available (Accessed 23rd August 2020).
[36] S. K. Appicharla, "Cross Rail Train Protection (Plan B) - Railway Safety Regulations," ORR, 27th October 2015. (Online). Available: (Accessed 18th May 2019).
[37] Prof Philip N. Johnson-Laird, Department of Psychology, Princeton University, Princeton, NJ 0854, "Mental models and human reasoning," Proceedings of the National Academy of Sciences, vol. 107, no. 43, pp. 18243-18250. (Online). Available (Accessed 26th October 2010)
[38] Office of Rail Road Regulation, "Internal guidance on cost benefit analysis (CBA) in support of safety-related investment decisions," Office of Rail Road Regulation, London, 2015.
[39] Ali Hessami, John D. Corrie, Roderick Muttram, Roger Aylward, Brian Clemenston, Robert A. Davis, Bruce Elliott, Eddie Goddard, Chris Thompson, Dee Razdan, J. Irwin, Terry George, Andy Doherty, Yellow Book, London: Railtrack on behalf of the UK Rail Industry, 2000.
[40] R. Whittingham, The Blame Machine, Oxford: Elsevier, 2004.
[41] McDermott, Thomas A., Dennis J. Folds, Leonie Hallo, "Addressing Cognitive Bias in Systems Engineering Teams," INCOSE International Symposium, vol. 30, no. 1, pp. 257-271, July 2020.
[42] Dr. G.J. Bearfield; R. Short, "Standardizing Safety Engineering Approaches in the UK Railway," in The Sixth International System Safety Conference, Birmingham, 2011.
[43] The European Commission Directorate General for Transport, "The Master Plan for Development and Pilot Installations of the European Traffic Rail Management System Doc.189/96," The European Commission, Brussels, 1996.
[44] S. Appicharla, "Technical Review of Common Safety Method using System for Investigating Railway Interfaces (SIRI) Methodology," in 8th IET International System Safety Conference incorporating the Cyber Security Conference 2013, Cardiff, UK, 2013. (Online). Available: (Accessed 3rd August 2021).
[45] Halcrow Group Limited, "(CH012 Final Report National ERTMS Lessons Learnt Review Report," 4th April 2012. (Online). Available: (Accessed 26th October 2019).
[46] Sir John Bourn, The Comptroller and Auditor General, NAO, "The Modernisation of the West Coast Main Line," The HM Stationery Office, London, 2006. (Online). Available: (Accessed 22nd August 2019).
[47] Obi Ozonzeadi, Development Manager –Network Rail, Governance for Railway Investment Projects (GRIP) application for Thameslink Programme, London: Thameslink Programme, 2018. (Online). Available: (Accessed 12th June 2021).
[48] The NEL Consortium, "The UK HSE Research Report 067: Train Protection - Technical review of the ERTMS Programme Team report," The UK HSE, HMSO, Norwich, 2003. (Online). Available: (Accessed 6th August 2013).
[49] Sir Haddon Cave, QC, "THE Nimrod Review," 28th October 2009. (Online). Available: (Accessed 25th December 2019).
[50] Atsuo Murata; Tomoko Nakamura; Waldemar Karwowski, "Influence of Cognitive Biases in Distorting Decision Making and Leading to Critical Unfavourable Incidents," Safety, vol. 1, no. 1, pp. 44-58, 2015. (Online). Available (Accessed 3rd August 2021).
[51] T. T. &. M. Hunt, "Review of LU and RSSB Safety Risk Models," ORR, London, 2012. T. T. &. M. Hunt, "Review of LU and RSSB Safety Risk Models," 2012. (Online). Available: (Accessed 6th May 2019).
[52] P. A. Evans, “Transport Fatal Accidents and FN Curves,” HMSO, Norwich, London, 2003. (Online). Available: (Accessed 12th June 2019).
[53] Marius Wold Albert, MSc NNTU, "A case study to investigate accidents involving the European Rail Traffic Management System (ERTMS): Investigation of complex accidents in the digitalised railway sector," 2019. (Online). Available: (Accessed 11th June 2021).
[54] Andrew Smart et al, Google, "Closing the AI Accountability Gap: Defining an End-to-End Framework for Internal Algorithmic Auditing," in FAccT: Fairness, Accountability, and Transparency, Barcelona, Spain, 2020. Online. Available: (Accessed 30th March 2021).
[55] Prof T. Aven; University of Stavanger., "Risk Assessment and risk management: review of recent advances on their foundations," European Journal of Operations Research, vol. 253, no. 1, pp. 1-13, 16th August 2016. (Online). Available (Accessed 30th April 2019).