The crash at Kerang: Investigating systemic and psychological factors leading to unintentional non-compliance at rail level crossings.

In 2007 a loaded semi-trailer truck struck a passenger train on a railway level crossing in Northern Victoria, Australia, killing eleven train passengers. Although the incident was formally investigated, why the truck driver proceeded through the crossing in the presence of a train remains unexplained. This article uses two juxtaposed Human Factors approaches to provide insight into the contributory factors underlying the incident. A systems analysis framework is used to examine the rail level crossing system in which the incident occurred and an individual psychological schema theory account is used to examine the failures which led the truck driver to proceed through the crossing in the presence of a train. The findings suggest that the primary cause of the incident was a looked-but-failed-to-see error driven by a faulty activation of schema error, leading the truck driver to assume initially that the crossing was in fact in a non-activated state with no train present. Moreover, various system-wide factors that shaped the rail level crossing 'system' and thus the incident are identified.