Over a period of time EuroStar identified that they had been an increase in the number of incidents of trains being found in service with defects. Each of these incidents had been examined and found to be a 'one off', however, Eurostar had a concern that over a 12 month period there had been a significant increase in the number of 'one offs'. Therefore, PPWD were asked to undertake an Investigative Learning Review in accordance with the remit and scope as provided by Eurostar. The LR will as far as practicable establish the 'Whats, Whys and Hows' of the incidents, to understand why it made sense for those involved to do what they did.
PPWD decided to take a 'Systems Approach' and employ the tools and techniques that we currently use during post-incident investigations and learning reviews. This enabled us to establish as far as was practicable the technical and Human Performance factors which contributed and indeed, came together to create the occurrences. For example, are the current rules, regulations or standards too complex or contradictory? This approach also identified cultural and non-technical aspects which were influencing – communication, problem solving and decision making.
PPWD spent around half of the time in the 'field' viewing the Engineering Centre and the Eurostar Control Centre; interviewing, meeting, running workshops and chatting with those directly and indirectly involved in the occurrences. The remaining time was spent, reviewing documentation (procedures, methods of work, policies) and report writing.
PPWD identified a number of common themes that spanned all parts of the Eurostar organisation as well as themes specific to separate parts of the organisation. PPWD made a number of recommendations that mitigate the opportunity for such a set of circumstances to make sense or indeed come together in the future for similarly qualified and experienced personnel. These recommendations were then employed both within a Eurostar safety strategy and a business case, to target resources in the short, medium and long term.