The automatic system will fail at some points so manual dispatch is needed, which is how this all happened

Not OP but I'm imagining we'd ask the question why the "dispatcher ordered manual bypass ignoring the rest of the guardrails". They're saying it's all slices of cheese in a system that failed here.

It seems that one of the train conductors did know that it was not the procedure and tried to warn of the problem.

Trains take a long time to stop even at moderate commuter train speeds because they are so heavy, let alone high speeds of 300km/h+.

At least one of the failures here is that the dispatcher authorized such a high speed, in other systems I am familiar with, generally the procedure with a signal fault is to crawl at a speed such that the train can stop in line of sight distances.

In fact, that is the Spanish protocol, which for some reason was bypassed by dispatch even after the train driver had questioned it:

> Under normal protocols, the driver would be expected to continue moving at a maximum of 40km/h according to their line of sight, and not at normal speed on a track designed for speeds of up to 200km/h.

If a stretch of road continues to have frequent crashes even though a sign is present, it is worth examining why that sign alone is not solving the issue.

Air travel is as safe as it is because we don't stop the investigation at "pilot error" but instead ask why the pilot made the mistake, and why a single mistake was able to lead to loss of life.

I don't mean to pick, but it seems like you have near zero knowledge of how train systems work.

You are 100% dependent on your safety and monitoring systems because almost every problem that could come up is beyond the horizon of your human senses. Stopping distances are in thousands of feet to miles depending on the train size and weight. Add any curves and that's far beyond your visibility.

Then you add in management complaining that you're too slow and you need to do things faster and cheaper or you'll lose your job. Things turn from solution culture to blame culture.

Then you add in false errors and warnings in a system that teach you to ignore them and an upper management that doesn't fix them.

Then you have the day like hundreds of others where warnings are going off, management is yelling, but this time there is a stopped train around the corner and everyone dies.

This is a systemic problem.

> Someone was driving the train who couldn't estimate the stopping distance relative to speed.

The stopping distance for a train this size and this fast is around 2km. Good luck estimating that by sight. There is a reason the normal protocol has a 40km/h max speed for traveling according to line of sight, which the driver was told wasn't needed.

I wish this were true, but there is basically no consequences for drivers in the situation you described. The most egregious example I can think of near me was in 2022 when a kid was crossing a flashing crosswalk with his bike near Tacoma, and truck had stopped to let him cross. A woman ignored the crosswalk signal and used the adjacent lane to drive past the stopped truck and hit the kid, killing him. The woman was never criminally charged. She didn't even experience any consequences for her driver's license.

https://komonews.com/news/local/13-year-old-boy-killed-while...

Indeed, car crashes tend to just blame one (or more) of the drivers. Nobody excuses a foolish driver with systemic excuses.

On a surely unrelated note, car travel is by a substantial margin the most dangerous mode of transport most of us ever use, and the most dangerous activity most of us routinely engage in.