June 17, 2019 | Mark Paradies

NTSB Completes Washington State Train Derailment Investigation

Bad Human Factors or Training?

It was a dark morning. The signs for speed limits were not very obvious and were not in locations that were appropriate for passenger trains. This was the first revenue train down this new track. The engineer had driven a train down this track once before and knew there was a bad corner. But the engineer had not operated this type of train down that track, had only operated this type of engine a couple of times, and was not familiar with all of the alarms in the engine’s display system. Very little defense-in-depth in the speed control around this sharp turn, in this case, the engineer’s knowledge and spotting at least one of the two signs at night. What could go wrong???

Here is an NTSB video about a train wreck near Seattle that killed three people. Hear what the investigators have to say and the recommendations made. On the human factors evaluation, it seems that bad human factors (Displays NI and Labels NI) were major root causes. There were lots of other factors. The NTSB did recommend better signage along the tracks but didn’t talk about changes to displays inside the cab. Many of the human factors recommendations focussed on training. Watch the video and see what you think…

Here are some pictures from the report that you can refer to as you watch the video…

One more interesting fact in the video … When more than one person is responsible, no one is responsible. It seems we have once again violated Rickover’s safety rules.

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Accidents, Current Events, Root Cause Analysis
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