From white space to red flags: identifying authority gradients in rail incident investigations

A steep authority gradient, the difference in perceived or actual power between individuals, can create work environments where lower-level workers feel they lack the agency to make decisions or challenge authority. Although authority gradients frequently occur in organisations with entrenched hierarchies and influence safety-critical incidents, they are rarely identified as contributory causes. This gap is particularly problematic in the rail industry. This study examined how manifestations of authority gradients are uncovered or overlooked during rail accident investigations. A cross-sectional multiple case study combining document analysis and AcciMaps explored three rail accidents investigated by the National Transportation Safety Board in the United States, each involving deficits in teamwork. Primary source data, including investigation materials and interview transcripts, provided insights into status hierarchies, where experience was equated with expertise; employee silence, where team members shielded each other from blame; and peer monitoring mechanisms that positioned teams as self-regulating units. Viewing authority gradients through a systems lens revealed how culture shapes teamwork errors in rail and highlighted potential ‘red flags’ for investigators. Recognising these indicators may equip investigators to identify authority gradients as contributory factors, enabling targeted interventions to flatten gradients and strengthen team cohesion.