Comment by threetonesun
11 hours ago
Once upon a time I did root cause analysis professionally, and a trainer told us if you attributed the root cause to people without finding malice you were just being lazy. At the very least I doubt anyone to blame here was actually involved in the accident, but someone who decided it was not in the budget to put an automated system in place faster.
They had an automated system, it had failed earlier in the day in that section causing trains to be signalled to stop. Then they had a manual go-slow human backup protocol which appears to also have not been observed - some drivers were given clearance to continue as normal. Swiss cheese of compounded failures, with tragic results.
And what are the systemic practices in place that led to people not following the official protocol?
Because if the system punished compliance and rewarded such behavior, you now have a systemic issue underlying the "people are lazy".
> And what are the systemic practices in place that led to people not following the official protocol?
I guess we'll find out. Apparently one of two drivers who were given the go ahead for normal operations requested additional confirmation because he or she (rightly) thought go-slow was the expected response for transit resumption under the fallback protocol. Some incompetence in the control authority Adif, then, but I'm sure that'll be the focus of the inquiry they will no doubt have.
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I'm so fucking tired of you people constantly trying to reduce human accountability after accidents like this that claim lives. It's always the fault of the system and never the fault of any people. As if we are all just cogs in a machine that is controlled by no-one. It is your fatalistic worldview that is directly causing accidents like this. How many more people have to die before we can fix things? Just stop.
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