Just sent the following comment to CBC-Radio-1 "The Current"... The Producer, “The Current”, CBC Radio-1. The tragedy in Mégantic: Root-Cause Analysis. The tragedy in Mégantic reflects an UNACCEPTABLE situation, especially for a mature industry that can be intrinsically safe like the Railways. I will exclude from consideration the possibility of criminal action, such as tampering with parked equipment. However, THE OPERATING RULES HAVE TO BE FOLLOWED. What has happened here is strangely analogous to the human factor failures that led to the recent crash of Asiana Flt 214 in San Francisco. In the current context, there is a rather dubious evidence that, as the Rules Book used to say: “Safety is of the First Importance in the Discharge of Duty”. This appears to have been the result of a “Perfect Storm” leading to inadequate recurrent training, improper understanding of the Rules and a Corporate focus on the bottom-line, all this in a societal context that is really hostile to the Railways. Thus, the Rules have been allowed to degenerate into what I call a misleading “Illusion of Compliance”. I repeat what I stated earlier: this is totally UNACCEPTABLE - even if the “Run-Away” train had not carried dangerous goods or had been empty. Unfortunately, much of the discussion was skewed because of the misinformation that was circulated, often from self-appointed “Experts”. In reality, what may have looked good on paper, based on very narrow considerations, has set the stage for an unavoidable catastrophic system failure. This is something that the proper use of time-proven Operating Procedures would have necessarily DETECTED, thus preventing the tragedy from happening in the first place. Unfortunately, even though Railways used to have a strong “Safety Culture”, they have allowed this to degenerate over time. Furthermore, they failed to adopt the Aviation Industry concepts of “Crew Decision Making” and “Defense in Depth”.
Posted on: Tue, 16 Jul 2013 15:28:02 +0000
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