In this study, an initial systems-based analysis was performed within the Norwegian railway. This approach to system safety attempts to provide information regarding the latent, system-related factors leading up to an unwanted event. The primary data includes two semi structured group interviews with safety officials, two individual semi structured interviews with safety officials, one cognitive interview (CI) with a certified train driver, and two ethnographic observations with in-cab interviews. In addition, a total of 542 reports of Signals Passed at Danger (SPAD) were read and analysed. Leaving a station, out on the route, and approaching the station were found to be critical to train driving operations, while switching was suggested as a fourth system critical situation. The results suggest that there are several weaknesses within the Norwegian railway system which are likely contribute to unwanted events.