Train SPAD investigators in human factors and root cause analysis
Ladbroke Grove Inquiry · Ladbroke Grove Inquiry — Final Report · Issued 19 June 2001
Government responseNot tracked (historical inquiry)
DeliveryNo statement from the addressee found
Recommendation, verbatim from the inquiry
●Inquiry recommendation
Persons who investigate, and make recommendations as a consequence of, SPADs should be trained in the identification of human factors and in root cause analysis. Their competence in these areas should be formally recorded, and renewed by refresher courses. The analysis of SPAD data should be specifically directed to eliciting the part played by human factors and assessing the significance of the hazards against which the signals which have been passed at Danger were intended to afford protection (para 11.31).
Ladbroke Grove Inquiry, Ladbroke Grove Inquiry — Final Report · 19 Jun 2001 Source PDF →
Government response
●No formal government response recorded
The Index has not yet recorded a verbatim government response to this recommendation.
Delivery
No statement on delivery from the addressee has been found in the sources searched. This is separate from the response above.
How this page is built
The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.