Train SPAD investigators in human factors and root cause analysis
Ladbroke Grove Inquiry · Ladbroke Grove Inquiry — Final Report · Issued 20 September 2001
Source — 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 · 20 Sep 2001 Source PDF →
Response — verbatim from government
●No formal government response recorded
The Index has not yet recorded a verbatim government response to this recommendation.
Evidence trail — what's actually happened since
No published activity has been recorded against this recommendation yet.
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