System Based Risk Analysis of Signalling Protection Failures in Indonesian Railways Using HFACS and Multi Criteria Prioritisation

Abstract

Signalling-protection failures remain a recurring safety issue in Indonesian railway operations, particularly in high-density corridors. This study aims to analyse contributing factors and determine their priority using a system-based approach. The methodology integrates HFACS-Railway Accidents (HFACS-RAs) for factor identification, DEMATEL for causal relationship analysis, and the Analytic Network Process (ANP) for priority weighting. Data were obtained from 13 accident investigation reports published by the Indonesian National Transportation Safety Committee (KNKT) from 2015 to 2024, along with an illustrative case study of the 2015 Juanda collision. The results show that Equipment Resources appeared in all cases, while unsafe acts such as skill-based and decision errors were also frequent. However, DEMATEL analysis indicates that organisational influences and unsafe supervision act as upstream drivers, whereas unsafe acts are downstream outcomes shaped by system conditions. ANP results further reveal that operational factors such as delayed braking have high priority weights, but represent event-level mechanisms rather than root causes. These findings highlight the importance of a system-based perspective in understanding signalling failures, where human error is interpreted as a manifestation of broader system conditions rather than an independent cause.