April, 2013

201304AprAll DayA failure to follow proceduresPSF Learning Brief 004 Origin: PSF Lessons:Operating Procedures,Operational IntegrityLanguage:EN TagsRailways


At 23:29 on Saturday 22 October 2011, 16 year-old Georgia Varley was struck and killed by the train she had left 30 seconds earlier.

Lessons from this event apply to both management and the workforce. Management should ensure that procedures reflect all operating circumstances and are regularly tested for understanding, efficiency and risk control. Employees and contractors should be involved in the development and review of procedures; they should ensure that they follow procedures and, if they identify that procedures are in need of refinement, they should bring this to the attention of management through appropriate channels


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