FIGURE 1: Number of year on year incidents.

FIGURE 2: PRASA: Costs incurred with respect to collisions.

Hypothesis 2: The standard operating procedures are not clear and specific enough.

Hypothesis 3: Human error causes accidents due to non-compliance with the operating communication procedures.

If the Passenger Rail Agency is to provide a high quality service with safety as an embedded culture, a risk management approach is needed, as quoted from the advice of Kildow where it is stated:

If we agree that disasters are inevitable, it would seem logical that we must also agree that it is wise to take the necessary steps to manage our risks to the extent possible and to reduce the effects of disruptions through planning and preparedness (2011:xvii).

In the Gauteng Province, some of the types of incidents that took place between 2011 and 2012 were related to rear end collisions. The total amount lost by PRASA as a result of these collisions amounted to R52.40 m.

It is evident that the accident that occurred on 08 April 2011 at Winternest cannot be said to have been caused by ‘obsolete and malfunctioning of the signalling system’ because the driver passed the signal at danger prior to the collision. For the purpose of this study, Hypothesis 1 cannot be said to be valid as human error appears to have been the overriding reason for the collision.

Hypothesis 2: The standard operating procedures are not clear and specific enough.

Train operations have many specific standard train operating procedures that must be followed. The analysis of why these incidents occurred cannot be attributed to these procedures not being clear and specific enough; the human element remains the root cause of the incidents. It is therefore clear that Hypothesis 2 cannot be said to be absolutely valid.

Hypothesis 3: Human error causes accidents due to non-compliance with the operating communication procedures.

It is apparent that the root cause of these incidents involved human error as evidenced by the Railway Safety Regulator (2011:x), it states ‘Collisions are as a result of non-compliance with the operating communication procedures during train operations because of human error’. This empirical evidence therefore renders Hypothesis 3 valid.

There is therefore a need to review the regulatory safety procedures to ensure that the safety of PRASA is given the attention it deserves. This can be achieved by cultivating a culture of safety, business continuity and a favourable difference between life and death.

The management of risk in any human endeavour requires careful and objective consideration within the environment in which one operates. This should be the case with regard to PRASA’s train operation environment. It should be noted that the risk management process begins with understanding the elements of the transport system, identifying, assessing and managing the associated risk factors throughout the entire passenger rail transport system value chain.

Accidents often occur because of an accumulation of mistakes caused by train operating staff. Reason (2008:37) was of the view that mistakes are often difficult and sometimes impossible to discover because we do not necessarily know the ideal pathway towards an intended goal. Not achieving the desired outcome does not in itself signal a mistake. It is common that errors can take the form of systematic ‘absent minded’ action slips and memory lapses.

The concept of safety culture should be ingrained in the deepest, unconscious aspects of all departments of PRASA. It should be turned into a tangible concept and needs to touch every person within the organisation, and should influence the way in which people relate to one another.

This research adopts the assumption that ‘accidents are mainly caused by human error or failure’ (Antonsen 2009:9). According to this reasoning, a safety-conscious organisation can be designed by creating a management system that specifies objectives, distributes responsibility, plans, organises and controls according to safety precautions. PRASA should therefore ensure that human error is given attention throughout the entire organisationa.

Operating in a normal situation: Keyton (2011:8), was of the view that an organisation is in a normal situation when it is at a stage where it is dynamic and responsive to the market and adheres to the regulatory environment. The market environment of PRASA refers to passengers and the regulatory environment is represented by the Railway Safety Regulator. It is at this stage where a considerable amount of intensive communication with respect to safety culture has to take place within and across departments of the entire PRASA.

Keyton (2011:10) further argued that ‘everything an organization does is done through its members who process and communicate information from both internal and external sources. PRASA need to ensure that its institutional memory is sustained by preserving safety culture knowledge, behaviours, norms, and values over time’.

Operating at the incubation phase: This implies that that there will be signs or symptoms that things are about to go wrong before the onset of the crisis. An example would be repeated violations of procedures as symptoms of an organisation being in a state of incubating an accident. When this happens to an organisation such as PRASA, the logical step would be to detect the danger signals and to start instilling an appropriate safety culture. The primary mission of analysing the incubation period is to assess how errors develop towards the trigger point. The incubation phase ends when the different latent factors coincide to create the event that triggers the disaster. This way of viewing accidents as created by the occurrence of latent conditions and active failures has been highly influential for later accident models as shown in Figure 3.

FIGURE 3: Accident investigation model.

Emerging crisis: Proponents of high-reliability organisations are of the view that cultural aspects play a fundamental role in maintaining safety. Culture is viewed as an important informal co-ordination mechanism, which can constitute an alternative to the structural centralisation concentrated at the corporate level of an organisation. This is also viewed as a way of dealing with the risks connected with extremely complex and tightly-bound organisations and technologies. In addition to instilling safety culture, an organisation like PRASA needs to cultivate the safety climate, which is referred by Antonsen, as a situation:

… where managers at all levels are highly committed to safety, where the workforce express satisfaction with and adherence to the organisation’s safety system, where everyone is risk averse, where there is no pressure towards maximising profits at the expense of safety and where operators as well as managers are highly qualified and competent (2009:17).

Rescue, crisis management: The United Nations Human Settlements Programme (2007:167) asserted that an entity is said to be in a crisis situation when life support systems fail in the face of pressure from external stress, resulting in loss of life, damage to property and the undermining of livelihoods. This situation is reached when an accident occurs and the focus is on rescuing those who are trapped. Given the extreme challenges the PRASA train drivers face in their work environment due to systems failures, an intervention is sought to normalise the operation.

Antonsen (2009:15), argued that organisations that value case studies about past safety issues are more reliable in the competitive landscape. PRASA should consider holding symposiums where case studies are presented as evidence of how safety regulations and procedures can be implemented at the accident scene. In this way the communication of safety-critical knowledge throughout the entire passenger rail industry is indispensable as this would strive to restore the safe operations and thus promote the safety culture. This could be done by bringing back retired employees who would disseminate safety cultural stories amongst the train operating staff.

Cultural adjustment: Keyton (2011:10) advised that for cultural adjustment to take place there has to be several streams of communication through multiple channels in multiple contexts. Safety cultural diffusion should be encouraged; ranging from informal communication, such as a guest speaker, to extremely advanced formal communication, such as a safety conference.

For PRASA to undergo cultural adjustment and revert to a normal operating situation, it has to operate as a flexible, interactional system, which is composed of layers of ongoing conversations about safety culture. When information is shared amongst organisational members and codified in some way, an organisational interpretation will exist beyond that of its individual members. These interpretations will get passed from employee to employee, creating what is referred to as ‘thread of coherence’ (Keyton 2011:10) even though there may not be full convergence. The interactions of individuals create an organisational-level interpretation that can be passed on to others. Operating in the normal situation can be sustained by a holistic application of safety climate and culture.

The increased interest in the relationship between culture and safety is associated with a shift in the way we think about how organisations are created, managed and how they function. The classical view of organisations rests on an assumption that organisations and their members act according to rational principles.

… a pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems (2011:19).

In his book, Tang (2011:9) argued that if one has to effect institutional change, the source of change must be endogenous. Derived from this wisdom, it would be advisable for the passenger rail transport industry to ensure that the source of the safety culture be from within and should be communicated effectively to reach the targeted audience. Effective communication would render a dynamic safety culture, as it is not fixed or tied to a specific physical location or to a specific collection of people.

• Consider exploring more advanced Automatic identification systems (AIS) in the passenger rail transport industry. This would serve as a new technological intervention to assist drivers in their daily operations.

• Safety should be demonstrated throughout all organisational human work and should not be confined to safety-critical and safety-related grades only.

• Effective communication within and across departments should form a favourable stimulus to unleash safety cultural diffusion within the entire organisation.

In conclusion, it is of fundamental importance that safety culture be instilled and engineered amongst the total work force, in order to improve safety of the passenger rail transport industry in South Africa.

For safety climate and culture to be sustained there has to be improvement by means of:

• Developing safer machines and equipment.
• Increasing focus on improving safety through strategic recruitment.
• Upgrading employees’ technical skills.
• Making efforts to increase employee motivation by improving work at the individual level.

Grigg, N.S, 2010, Infrastructure Finance: The business of infrastructure for a sustainable future, John Wiley & Sons, New Jersey. http://dx.doi.org/10.1002/9781118266182

Keyton, J., 2011, Communication and Organisational Culture: A key to understanding work experiences, SAGE, London. PMid:23223093, PMCid:PMC3513779

Kildow, B.A., 2011, Supply chain management: Guide to business continuity, AMACOM, New York.

Rausand, M., 2011, Risk Assessment Theory, Methods, and Applications, John Wiley, New Jersey.

Reason, J., 2008, The Human Contribution Unsafe Acts, Accidents and Heroic Recoveries, Ashgate Publishing Company, Burlington.

Railway Safety Regulator, 2011, South African Railway State of Safety Report 2011/2012.

Teegarden, P.G., Hinden, D.R. & Sturm, P., 2011, The Nonprofit Organizational Culture Guide: Revealing the hidden truths that impact performance, Jossey-Bass, San Francisco.