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points by threetonesun 1 day ago | 0 comments

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.

[–] guiriduro 1 day ago

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.

[–] sdoering 1 day ago

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".

[–] guiriduro 1 day ago

> 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.

[–] port11 1 day ago

To be fair, train crashes happen rarely enough that the safety procedures are in place and work (at least most of the time).

[–] baobabKoodaa 1 day ago

In Spain they appear to happen rather frequently

[–] baobabKoodaa 1 day ago

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.

[–] awhitby 1 day ago

Obviously individual people can be at fault, but it is this further process of asking _why_ individual people fail—pointing to systems, procedures, cultures—that has (in part) contributed to the extraordinary safety of aviation.

So I would say on the contrary, it is that systems worldview that actually leads to lasting improvements. Because human nature is not changing in a hurry.

[–] jiggawatts 1 day ago

Systems and procedure are created by people.

Culture is literally just “how people collectively behave”.

It’s people all the way down!

If you update the artefact without replacing its creator, they’ll just “fix” it to their taste again when you leave.