https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf
Skimming through it rather confirms what I suspected based on the >information available earlier - the procedures in use to manage the
signal outage were inherently unsafe.
I'm left aghast by the fact that train authorities did not have to be
read back. The people who made that decision have no understanding of
human factors risks, and have no business being anywhere near the sharp
end of train operations.
We don't know, and never will know, exactly why the driver did not slow
the train to enter the loop, but any system that relies on a single
person to know of the unusual need to slow, and to remember to do so,
was just an accident waiting to happen.
Sylvia.
On Wed, 9 Aug 2023 23:36:08 +1000, Sylvia Else <sylvia@email.invalid>
wrote:
https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf >>
Skimming through it rather confirms what I suspected based on the >>information available earlier - the procedures in use to manage the
signal outage were inherently unsafe.
I'm left aghast by the fact that train authorities did not have to be
read back. The people who made that decision have no understanding of >>human factors risks, and have no business being anywhere near the sharp >>end of train operations.
We don't know, and never will know, exactly why the driver did not slow >>the train to enter the loop, but any system that relies on a single
person to know of the unusual need to slow, and to remember to do so,
was just an accident waiting to happen.
Until money, a lot of money is spent on tracks keeping train speeds
below that of a bicycle and lower more of this will come
Petzl <petzlx@gmail.com> wrote:
On Wed, 9 Aug 2023 23:36:08 +1000, Sylvia Else <sylvia@email.invalid>
wrote:
Skimming through it rather confirms what I suspected based on the >>>information available earlier - the procedures in use to manage the >>>signal outage were inherently unsafe.https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf >>>
I'm left aghast by the fact that train authorities did not have to be >>>read back. The people who made that decision have no understanding of >>>human factors risks, and have no business being anywhere near the sharp >>>end of train operations.
We don't know, and never will know, exactly why the driver did not slow >>>the train to enter the loop, but any system that relies on a single >>>person to know of the unusual need to slow, and to remember to do so, >>>was just an accident waiting to happen.
Until money, a lot of money is spent on tracks keeping train speeds
below that of a bicycle and lower more of this will come
You presumably mean "above", not "below".
But actually this talk in
the media about the need for technology upgrades overlooks the fact
that this was primarily caused by, as Sylvia stated, a procedural
issue. Stupidly implemented technology is no more safe than
stupidly implemented low-tech solutions. Saying better technology
will fix everything is just the typical line of governments
throwing money at a problem instead of facing the awkward issue of
people in authority actually being at fault.
More technology wouldn't have prevented this - they were running in
degraded mode anyway due to other work in progress. Normally there WOULD >have been warning to the driver that they were taking the loop (oi -
that signal isn't showing what I expect!)
What needs to be examined is the processes and check-n-balances in that >process when running 'degraded'.
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