Author(s)

F. Jubert

Abstract

From November 2005 to December 2012, an average of 6 trains per year departed with their doors open for the regional express railway lines exploited by the RATP in Paris. Aside from these general figures, the statistics do little to explain such incidents. For this reason, it is necessary to carry out a qualitative study in order to better understand this phenomenon.

Having examined all reports on the 46 open-door departures recorded over the analysis period, in addition to some driver interviews, the study succeeded in characterising the different types of errors that cause these incidents. The “split of double capture” that occurs when a driver shifts his attention to something other than the door service at the time of departure accounts for about 60% of the cases with known causes. The remaining 40% are caused by “omissions” following an unexpected interruption while carrying out the traveller service. Although the unawareness of focusing mechanisms makes it impossible to eliminate the problem, the conspicuous nature of the interruption allows drivers, when required, to implement two practices aimed at a better management of sequence breaks. The first consists of a “no interruptions” policy when launching the closing sequence. If the interruption is unavoidable however, the second practice will enforce a “start from scratch” policy when recommencing the door service. However, in order to be implemented, the latter practice assumes that the driver is doubtful over state of the door service, which is not always the case. The recorded incidents following sequence breaks attest to this.

On the basis of these different observations, the study sought to define the triggers likely to limit the occurrence of such incidents or, more specifically, to stem the production of driving errors that cause these incidents.

Keywords

railway safety, risk management, human performance practices