Transcript Document

Rail & Aviation Standing Group
21st May 2009
Rail Industry use of Simulation,
Organisational treatment of Driver Error
&
Managing errors occurring during the
Simulator session
Presenter introductions
Malcolm Cook
Chairman of the UK Rail Industry Simulator User Group.
Simulator Manager First ScotRail Glasgow
A view from both sides of the fence
1972 - 2000
13 Years
Armoured
Vehicles
15 Years Army
Pilot
Instructor and
Troop
Commander
3 years TD
Analyst HQ
DAavn
A view from both sides of the fence
2000 -2009
Presentation Outline
• An introduction to the scope of Rail Industry Simulator use
• Similarities with Aviation and the Military
• Differences and barriers
• Challenges to be managed in the introduction of “Just Culture”
• Initiatives and the development of usable tools
• Next steps?
Who has Train Driving Simulators
How many Train Driving Simulators?
Full Cab Simulators
Part Cab Simulators
26
19
45 simulators delivered
Operational?
Simulator League Table Jan 2009
13
27
10
6
12
9
51
6
5
5
PI / Alion
3
5
NIR/Eurostar/DB
Simulation for Similar Worlds?
Aviation, Military, Railway Similar ?
Which am I describing?
• Regulated environment
• Hierarchical Management Structure
• Continuous competency
assessment
• Highly trained skilled individuals
• In the public eye
• Esprit de corps
Ethos and Culture
All are far from 9 to 5
but the workforce and
management systems are
developing at very different rates
Similar Solutions in Similar Worlds
• Systems Approach to
Prepare
Job specification
Write training
Objectives
Training (SAT)
Recognise any of these terms?
• Training needs Analysis
Analyse
the Job
Determine
training content
Systems Approach to Training
• Task and Risk Analysis
Modify or
update training
Design training
Validate
training
Conduct
training
Changes in management systems
• On major equipment change
• In response to procedural change
• Prior to the introduction of new training media
Summary of Similar Worlds
• Similar Management Systems
• Similar Competency Assessment needs
• Similar consequences
Significant differences / challenges
• Expenditure, Military, Aviation, Rail Industry
• Time and Technology
• UK Rail Franchise system
• Traditional Workforce and Management
• Compliance or Competence
• Accountability, Corporate, Workforce and ROGS
Presenter introductions
Justin Willett
Head of Operational Training National Express East Anglia
No Industry Standard or Consensus?
“Questioning
individual
only be
• Some operators have chosen,
or are notthe
allowed
(Tradeshould
Union objections)
to
used to supplement other assessment
use their simulators for assessment.
methods, as knowledge alone cannot be
• Others simply assess minimum
compliance
rule book
standards
assumed
to inferagainst
competence.
Therefore
alternative
• Some allow serious errors
to happentechniques may need to be used
including….. use of simulators”
-This can be a powerful learning
event
Ref: ORR RSP1
-De-brief afterward, Ideally, but not always followed by a re run of the event.
(simulators)
can give a more predictive
• Others stop just prior to theThis
serious
error
assessment of the candidate’s behaviour
-Driver to explore their awareness of what is about to occur (SA)
because the same operating pressures can be
-Re run mandatory
placed upon them that they would undertake
within the work place.
RSSB: RS501 Good Practice Guide on Simulation
Challenges to the use of Simulators in a “Just Culture”
Culture & Expectations “but It’s only a game”
Before
• “I don’t see why I have to be assessed on a pretend train”
• “I have come for a play on your Playstation”
• “I’m not good on it because I don’t play computer games”
• “Its not real, so it doesn’t really matter”
• “It should be a training tool only”
• “If you want to test me, come out on my train”
• “I would not do that if it was a real train on my route”
After
“Best place to make mistake... I learnt a lot from that”
ScotRail Driver & NXEA Drivers
“It’s not as bad as I thought it was going to be”
“You deliberately tricked my Driver in to making an error”
“My Driver would not have done that driving a real train”
ScotRail Diver Team Manager
& NXEA Driver Manager
Expectation Challenges to “Just Culture”
• What encourages these errors?
• The situation, unpractised event - do we increase the opportunity
• The culture, it’s only a game
• The individual, lack of competence
• Simulator Driving
• False reading as modified behaviour for the simulator assessment only
• Assessment performance prejudiced by the anxiety levels
• Peer Group Information transfer
• The Simulator? “yeah it’s not bad”
• “When on your simulator assessment, don’t forget to……..”
Initiatives and Development
NXEA
Simulators are integrated into the
assessment process
Issues (1)
Compliance based assessment process
• How a task is performed is also important
• Non-technical skills play key role in incidents
and accidents
• How can this be measured in a meaningful
and consistent way?
Initiatives and Development
NXEA
Issues (2)
There can be an historical Punitive approach to error
• Errors can be a effective learning tool and/or a
precursor to poor ‘real world’ performance?
• Note on record/ formal incident/ license suspension
• Driver anxiety “what happens to me if I make a
mistake?”
Initiatives and Development
NXEA
Working with the HF team at RSSB
Identify
relevant non
technical skills
Develop
behavioural
markers
Key Behavioural Markers
Skill
1 Attitude to simulator experience
2 Confidence
1
8
Clarity
rd
za
/
em
ag
an
ide
nce
8.4
8.3
Ha
8.1
Problem solving/ diagnosis
8.2
Option generation
8.3
Risk assessment/ option choice
8.4
Outcome review
5.3
6.2
W orkloa
d manag
ement
6.1
veness
asserti
re
ne
ss
6.3
6
5.1
5.2
ne
ss
Checking behaviours
und
er
7.4
aw
a
Anticipation
ab
7.3
7.1
ap
pro
ach
l
ai
Out-of-cab awareness
7.2
tic
t
de
7.2
3.3
to
In-cab awareness
Sy
ste
ma
n
io
7.1
Ou
s
es
ren
wa
ba
a
c
ft-o
ing
Calm under pressure
7.3
Prioritis
6.3
tion
Anticipation
nt
te
7
Concentration/ managing distraction
rity
Cla
rma
g info
Sharin
viours
3
Non-technical skills
Prioritising
6.2
3.2
t
At
6.1
ing be
ha
Ca
lm
Rule compliance
Check
In
olvin
g
In
-c
5.3
7.4
n
le
ty
n
tio
ica
un
Attention to detail
ls
na
so
er
p
er
e
lnecs
lriua
mtop
dcoe
tilteu
Atu
R
8 Error/ hazard
management
(Assess during
feedback session).
5.2
ess
aren
7 Situational
awareness/ hazard
identification
Systematic, organised approach
Pro
blem
s
aw
nal
atio
Situ
6 Workload
management
5.1
8.1
ge
ne
ra
tio
mm
Co
5 Conscientiousness
io
n
ent
4 Assertiveness
3.1
e review
8.2
O
pt
2
Co
nf
m
Outco
Sharing information
rm
ro
er
to sim
t
en
ssm
sse
ka
Ris
3.3
Attitude
C
on
sc
ie
nt
io
us
3.2
Interpersonal style
Conce
ntratio
n
3.1
pre
ssu
re
3 Communication
5
4
Initiatives and Development
NXEA
Working with the HF team at RSSB
Identify
relevant non
technical skills
Develop
behavioural
markers
Non technical
skills toolkit
5.1 Systematic approach
Positive Indicators
Takes an organised systematic approach.
Unhurried, well timed actions, controlled
movements (overlaps with calm under
pressure)
Well organised e.g. all relevant paperwork
to hand and a generally well managed cab
environment
Negative Indicators
Unsystematic cab set-up
Rushed, less controlled movements
Disorganised e.g. papers covering in-cab
displays
Examples
Examples of
Performance
Statements that
satisfy the criteria
Sets up cab in a systematic way.
Controlled movements e.g. brake control.
5.2 Attention to detail
Positive Indicators
Negative Indicators
Where written material is used, reading
carefully e.g. demonstrates understanding
Demonstrating that they are listening carefully
e.g. where instructions are given, driver
concentrates and repeats back correctly, notices
mistakes
Accuracy in communication and writing, notices
others mistakes where applicable
Balances appropriate attention to detail without
losing sight of the overall perspective of
tasks/situations
Where written material is used, does not
read with care e.g. misunderstands, does
not notice mistakes if they occur
Does not show signs of listening e.g.
distracted, no eye contact, does not notice
mistakes if they occur
Inaccuracies in communication and writing
Becomes overly absorbed in detail and
misses the broader perspective, gets caught
up in unnecessary detail
Accurate completion of drivers’ report
Mistakes on drivers’ report
And the behaviour
observed that
meets the
performance
Initiatives and Development
NXEA
Working with the HF team at RSSB
Identify
relevant non
technical
skills
Develop
behavioural
markers
Non technical
skills toolkit
Training the Sim
Operators on
observation &
Feedback
Where did the error happen?
Suggested areas for development
Both Technical & Non Technical
Just Culture what would you do?
No Industry Standard or Consensus
As Just Culture practitioners how, do you think the Rail
Industry should deal with this Driver?
A remove the driver from driving and investigate the incident pending discipline
B debrief the driver and return him to normal operation
C explore with the driver the lapse of competence, return him to normal
operations and disseminate the outcomes to all
D removed the driver and re-brief prior to returning to operations, then place
him on a remedial action plan to additionally monitor their performance
No Industry Standard or Consensus
Would your decision be different if……………….
• Incident was reported externally
• Incident is reported by Driver
The consequence of passing that signal at danger would be a certain
collision with a 100 + mph express train.
Would your decision be different now if you are……………….
• The Managing or Safety Director of the franchise
• A passenger on the express train with your wife and children
Summary
A Just Culture is the aspiration of many of our colleagues and
something we believe strongly, will bring a sea change in terms of
Railway Safety.
The barriers can be overcome but…
• The structure of the franchise system
• Corporate and individual responsibility
• The culture of proportioning blame to show action has been taken
These barriers present us with significant challenges to manage the
change from a “Blame Culture” to a “Just Culture”
The use of Simulation in Driver Development
Our Industry's Strategic Weapon
But its not a panacea
for poorly managed training and assessment regimes
We need an effective “Just Culture” to support these regimes
Rail & Aviation Standing Group
21st May 2009
Any Questions Please