Comment by dimal
18 hours ago
Usually when you look deeper at failures like this, it’s because there’s a morass of bad incentives from the surrounding human system that enforces this kind of behavior.
Here is a plausible alternative explanation:
They’ve probably seen false warnings over and over and overridden them enough times that they lost sense of the risk. They need to keep trains on schedule, using a buggy system, with a manager looking over their shoulder. They override the warnings over and over, nothing goes wrong, and they forget that it may actually be right. Look at the Challenger explosion, Chernobyl, or any other failure like this, and there’s usually a bureaucratic process that has run amok, and the individual is just following perverse incentives that have been socially normalized over time.
So I’ll wait until I have more information before I proclaim this as human negligence and the system doing exactly what it’s supposed to do. We don’t know how often it was doing the wrong thing and confusing the fuck out of the human.
> "the individual is just following perverse incentives that have been socially normalized over time"
Normalization of deviance,
https://hn.algolia.com/?query=normalization%20deviance&type=...
Given this keeps happening in Spain, maybe we'll need to call this "Normalization of normalization of deviance".
Humans never learn.
"They need to keep trains on schedule, using a buggy system, with a manager looking over their shoulder."
Also lots of potentially angry passengers who want to get to their destination in time. Will miss important appointments, or even the last train connection for the day and be stranded if the train drivers decide to wait a little bit longer to be on the save side.
You also miss appointments and are late if you are dead due to a train crash.
I recently saw a doc on the 2013 Spanish crash and it was full of absurd system problems. The govt pinned it on the driver as best they could but it's clear that it was entirely preventable.
Jenga effectively. 3 others and Bob spent time destabilizing but Bob over here pulled the block before it collapsed. It's his fault.
> human negligence and the system doing exactly what it’s supposed to do
Negligence is not limited to the single human who issued the order. it's pretty unlikely that their order could have caused this without a significant amount of other negligence that eroded the safeguards. Nevertheless, the negligence is human, not machine in nature.
I did read from HN someone from Spain said that the system crashed very often that they had to rely on humans frequently.
Trains in spain have been running at reduced speed, delayed or even cancelled for a while due to aging infrastructure, which might've actually caused another deadly accident back in winter, so this behavior does not surprise me.
> Show me the incentive and I’ll show you the outcome
> -Charlie Munger
Normalization of deviance [0], wherein a clearly unsafe practice becomes considered normal if it does not immediately cause a catastrophe: "a long incubation period [before a final disaster] with early warning signs that were either misinterpreted, ignored or missed completely
[0] https://en.wikipedia.org/wiki/Normalization_of_deviance
It’s still gross negligence to place punctuality over safety, regardless of the reasons behind this behaviour.
I don't mean to absolve people for negligence, but when margins are very small and paychecks may have become a necessity to survive on this planet, sometimes within the complex process the collective behaviour gets pretty weird.
There are not that many people who (care to) see the big picture(s) and the consequences their semi-small actions may have in the long run.
(Un)Fortunately, finding someone who is "at fault" generally helps neither in investigating root causes nor in preventing similar problems in the future.
Usually it's detrimental, hence (criminal) investigations of personal liability in such cases are often only allowed after systemic investigation has concluded.
In court, you are allowed to withhold information that makes you look bad, which is simply lethally unhelpful when we want safer trains.
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