The first is on safety management systems. Railway companies have long been required to have safety management systems. The problem we see in our investigations is that these systems are not always effective. A safety management system must not be limited to a set of volumes in a library, for example. We also need to set up internal processes within companies to encourage employees to report incidents without fear of being punished.
For these processes to be effective, a culture of safety must therefore be established. Currently, we see that companies have safety management systems, but they are not effective enough.
The second recommendation pertains to the use of physical safety guards to prevent uncontrolled movements.