Technical Reports

Human Error Investigation Software Tool (HEIST)

  • 01
  • May
  • 2007
AUTHOR: Stephen Reinach1, Alex Viale1, and Donald Green2
OFFICE: RPD
REPORT NUMBER: DOT/FRA/ORD-07/15
SUBJECT: Human Factors
KEYWORDS: Human error, root cause analysis, railroad safety, human factors, HFACS
ABSTRACT: Human factors are a leading cause of train accidents and incidents in the United States. Human factors go beyond the crewmembers who operate the on-track equipment. They include management support and oversight, operating practices and procedures, technologies and facilities, and the work cultureā€”in short, the socio-technical environment in which railroad employees work. The purpose of this project was to develop a software tool to help Federal Railroad Administration personnel, and the railroad industry in general, systematically consider human factors issues at all levels of the socio-technical environment (or system) when investigating the causes or contributing factors of train accidents, incidents, and close calls. This report describes the development and features of the Human Error Investigation Software Tool (HEIST). HEIST is a portable Tablet and Windows-based application that can be used in the field, a hotel room, or an office to support accident/incident investigations. HEIST data collection tools include a checklist of things to consider; operator, front-line supervisor, and manager interview guides; a human factors taxonomy and definitions; an interactive data collection aid; and an online accident/incident/close call summary form. Data classification tools include an interactive aid and practice module. A HEIST user manual was also produced under separate cover. The report concludes with some recommendations for future enhancements to HEIST, including implementation of a centralized accident, incident, and close call database, and preparation of a field test.

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