Table of Contents
PREFACE AND ACKNOWLEDGEMENT ……………………………………………………………………….. I
PART I: BACKGROUND KNOWLEDGE
1 INTRODUCTION……………………………………………………………………………………………………. 3
1.1 Short overview of this thesis ……………………………………………………………………… 3
1.2 SPAD: a striking, unintended and possibly dangerous event…………………………. 3
1.3 Societal developments: better and more services…………………………………………. 5
1.4 Increased network load: less reliability and more SPADs…………………………….. 7
1.5 Research objective and approach………………………………………………………………. 9
2 BASICS OF RAILWAY ORGANISATION AND OPERATION……………………………………………… 15
2.1 Introduction ………………………………………………………………………………………….. 15
2.2 Players and markets in the railway sector ………………………………………………… 15
2.3 Control processes in railway operation ……………………………………………………. 26
2.4 Conclusion……………………………………………………………………………………………. 39
3 ANALYSIS OF EXISTING RISK CONTROL MODELS……………………………………………………… 41
3.1 Introduction ………………………………………………………………………………………….. 41
3.2 Basics of safety science ………………………………………………………………………….. 41
3.3 Overview of existing approaches to explain accidents………………………………… 44
3.4 Conclusion……………………………………………………………………………………………. 50
PART II: THEORETICAL FRAMEWORK
4 AN INTEGRATED RISK CONTROL MODEL: THE SAFE ENVELOPE OF OPERATIONS ……………. 55
4.1 Introduction ………………………………………………………………………………………….. 55
4.2 Development of the safe envelope so far …………………………………………………… 55
4.3 Terms and definitions …………………………………………………………………………….. 57
4.4 Balancing attention between safety and quality…………………………………………. 61
4.5 Further development of the safe envelope in a railway context……………………. 61
4.6 Illustration of an accident in the safe envelope model ………………………………… 66
4.7 Lessons learned from applying the safe envelope model …………………………….. 69
4.8 Discussion…………………………………………………………………………………………….. 73
4.9 Conclusion……………………………………………………………………………………………. 74
5 PROCESS CONTROL WITHIN THE SAFE ENVELOPE…………………………………………………….. 77
5.1 Introduction ………………………………………………………………………………………….. 77
5.2 Cybernetics …………………………………………………………………………………………… 77
5.3 Detect – Diagnose – Act: three general control subprocesses……………………… 81
5.4 Same subprocesses in other fields ……………………………………………………………. 83
5.5 Discussion…………………………………………………………………………………………….. 86
5.6 Conclusion……………………………………………………………………………………………. 89
6 THE THEORETICAL FRAMEWORK: A MIX OF MODELS AND METHODS………………………….. 91
6.1 Introduction ………………………………………………………………………………………….. 91
6.2 Combining the models ……………………………………………………………………………. 92
6.3 Collecting and processing of data using a grounded theory approach …………. 93
6.4 Conclusion……………………………………………………………………………………………. 99
Contents v
PART III: UNDERSTANDING THE CURRENT SITUATION
7 THE TRAIN CONTROL PROCESS …………………………………………………………………………… 103
7.1 Introduction ………………………………………………………………………………………… 103
7.2 Signalling from a control perspective …………………………………………………….. 104
7.3 The Dutch signalling system and its practical use ……………………………………. 114
7.4 Driver human factors …………………………………………………………………………… 124
7.5 Train control in safe envelope terms ………………………………………………………. 138
7.6 Conclusion………………………………………………………………………………………….. 140
8 THE TRAFFIC CONTROL PROCESS ………………………………………………………………………… 143
8.1 Introduction ………………………………………………………………………………………… 143
8.2 Route setting: assigning infrastructure to users……………………………………….. 144
8.3 Rescheduling infrastructure use …………………………………………………………….. 151
8.4 Traffic control human factors………………………………………………………………… 157
8.5 Ambiguous practices: cooperation with other actors ……………………………….. 159
8.6 Traffic control in safe envelope terms …………………………………………………….. 163
8.7 Conclusion………………………………………………………………………………………….. 165
9 INFLUENCES FROM DESIGN ………………………………………………………………………………… 169
9.1 Introduction ………………………………………………………………………………………… 169
9.2 Designing the service offer……………………………………………………………………. 170
9.3 Designing and supporting the operational processes ……………………………….. 173
9.4 Design of safety systems ……………………………………………………………………….. 179
9.5 Design and management in safe envelope terms………………………………………. 206
9.6 Underlying causes: management responsibilities …………………………………….. 208
9.7 Conclusion………………………………………………………………………………………….. 215
PART IV: DISCUSSION AND FUTURE
10 HOW TO IMPROVE SAFETY AND QUALITY OF SERVICE?…………………………………………… 221
10.1 Introduction ………………………………………………………………………………………… 221
10.2 Short summary of current operational control problems…………………………… 222
10.3 Reflecting on the theoretical framework …………………………………………………. 223
10.4 Unravelling the problem (A): Encourage operators to report surprises ……… 227
10.5 Unravelling the problem (B): Improve cooperation between operators………. 228
10.6 Unravelling the problem (C1): Learning from actual operations……………….. 232
10.7 Unravelling the problem (C2): Traffic control improvements ……………………. 237
10.8 Unravelling the problem (C3): Train control improvements ……………………… 239
10.9 Discussion…………………………………………………………………………………………… 243
10.10 Conclusion………………………………………………………………………………………….. 249
11 CONCLUSIONS AND RECOMMENDATIONS……………………………………………………………… 251
11.1 State of the art in research and need for additional knowledge………………….. 251
11.2 Framework to understand process control, safety and quality of service…….. 252
11.3 Explanations for the current quality and safety problems in railways ………… 254
11.4 Improving risk control measures and their modelling in railways ……………… 256
11.5 Recommendations………………………………………………………………………………… 258
REFERENCES …………………………………………………………………………………………………… 261
vi Modelling Risk Control Measures in Railways
PART V: APPENDICES
APPENDIX A EXAMPLES OF CURRENT PROJECTS …………………………………………………… 279
APPENDIX B INTERVIEW QUESTIONNAIRE……………………………………………………………. 287
APPENDIX C SUBSEQUENT MEANINGS OF THE YELLOW SIGNAL ASPECT …………………… 289
APPENDIX D LEARNING FROM SPAD DATABASES………………………………………………… 291
APPENDIX E COSTS AND BENEFITS …………………………………………………………………….. 297
GLOSSARY………………………………………………………………………………………………………. 303
SUMMARY ………………………………………………………………………………………………………. 305
SAMENVATTING ………………………………………………………………………………………………. 311
CURRICULUM VITAE ………………………………………………………………………………………… 319
NGINFRA PHD THESIS SERIES ON INFRASTRUCTURES …………………………………………… 321
Abstract
Safe, high-quality and more frequent rail services are desired by both society and passengers. Since large scale infrastructure extensions to accommodate higher train frequencies are hardly practicable, a more intense network utilisation is considered the way to achieve these aims. As a result, trains will get in each other’s way more frequently, which can lead to an increase in delays and incidentally to safety hazards if a train fails to stop. In order to understand how all objectives can be achieved simultaneously, without the disadvantages of a more intense network utilisation, a model is required that takes both the objectives and the risks of a process into account. Such a model, the so-called safe envelope of operations, has been developed in this thesis. By taking a functional view, it allows to combine human, technical and organisational factors; three elements that each play a role in railway design and operation. An extended survey of railway practitioners and literature has been performed to see how the railways are controlled in practice and how this was initially intended. A main conclusion is that improvements to the railway’s real time controllability are necessary to solve conflicts between train movements in an anticipatory way. Also several instances were found in which design changes and informally developed practices led to surprising results in practice. Information about actual operations must be shared to avoid operational surprises.
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