A systems analysis of fatal railway level crossing crashes

Fatal railway level crossing crashes represent a public safety challenge. Existing data on these crashes is limited, mostly focusing on frequencies rather than providing an in-depth understanding of the underlying causes. This study aimed to demonstrate the utility of using coronial findings, supplemented with reports from investigation agencies, to understand the system-wide factors contributing to railway crossing crashes and to explore the proposed recommendations. A systems thinking accident analysis approach, the AcciMap technique, underpinned the analysis. Over a 20-year period, 151 cases were identified, involving a range of road user types. Of these cases, 135 included sufficient detail to extract contributory factors and recommendations. A total of 483 contributory factors were extracted and used to develop an aggregate AcciMap. Most factors were associated with road user behaviour and/or individual characteristics, as opposed to systemic issues. Unique contributory factors were identified for crashes occurring at active crossings (those with dynamic warnings present) versus passive crossings (those with signage only). A total of 184 recommendations were extracted and mapped using the AcciMap framework. Recommendations tended to take a system-wide view of preventing future occurrences, acknowledging the complexity of managing risk at the interface of two transport modes. The analysis provided important information to support crash prevention efforts, including a set of common systemic recommendations identified from the data that require collaborative efforts across road and rail stakeholders. Mechanisms for supporting this collaboration should be further explored. The study also provided learnings regarding the nature of coronial investigations and areas for potential improvement.