Railway yard work instructions
Implemented
Rail R
Accident
24.9.2012
R2012-01/S327
Suosituksen perustelu
It was found in the investigation that the railway yard work instructions do not take account of all situations arising during normal work. Instructions for safety-critical operations should be presented as a checklist, in order to make work as standardised and uniform as possible, instead of working from memory. A checklist would help to avoid a situation where issues are forgotten.
Recommendation
The railway yard work instructions should be developed in order to take account of all situations arising from normal work. Safety-critical instructions should be presented as a checklist.
Toimenpide-ehdotukset
It was found in the investigation that the railway yard work instructions do not take account of all situations arising during normal work. Instructions for safety-critical operations should be presented as a checklist, in order to make work as standardised and uniform as possible, instead of working from memory. A checklist would help to avoid a situation where issues are forgotten.