Thinking about system failures in the recent Spanish train crash – comments from Harold Thimbleby

After the Spanish railway incident (July 2013) a number of news reports (1) focused more on the role of driver error than any failing of the technology or systems (2) involved, although this aspect has often been mentioned in comments on articles.

red signal fast train

Professor Harold Thimbleby from Swansea University’s FIT Lab and one of the Principal Investigators on the CHI+MED project has written the following for our blog, on the issue of the driver being at fault.

“Of course that’s possible, but it isn’t the full story by a long way. When an incident occurs, as James Reason shows, every defence fails. In this case, everything failed as well as the driver.

Here, obviously the train left the track, and that’s certainly a simple technical failure — so the technology is definitely a part of the cause. What happened to speed limiters, check rails, signage — lots of technical issues? These technologies either failed or were not present, which is another sort of error, design failure. Clearly driver error, whilst making an emotional newspaper story, isn’t the whole story, and certainly not to the exclusion of thinking carefully about the way the technology failed all those people.

And then what about training, company culture, the company calling the driver on a phone, why is there only one driver, and so on, which aren’t the usual meaning of driver error? This is a high-speed train taking a route the railway prides itself in being fast on, and the train is evidently designed to go too fast for the corner and the corner was designed to be too sharp to be taken by the train. Apparently the driver is well known for liking to go fast thanks to his Facebook comments; Renfe, one infers, decided to condone this behaviour over a long period of time. I recommend Phil Zimbardo’s The Lucifer Effect: Understanding How Good People Turn Evil here — although worked out in a different field, it makes the strong point that the culture is to blame for most people falling into doing bad things. Where was the oversight in this driver’s work? Certainly calling him on the phone when he is driving suggests safety wasn’t a prime concern.

We’ve known for over a century that drivers make slips; the fact that slips are part of a cascade of failing defences is nothing new, except that we’ve had technology available to prevent this for years, certainly if indeed it was a simple case of speed too high for the track. In short, “the system” made significant choices, no doubt primarily saving in the cost of technology investment, over a period of time so that sooner or later an accident like this would happen. And, again as James Reason says, since any driver could foreseeably have had this accident, then prima facie the system not the driver is to blame.”

Harold Thimbleby is professor of computer science at Swansea University, Wales. He was elected to Fellowship of the Royal College of Physicians, Edinburgh in 2012, and to an honorary Fellowship of the Royal College of Physicians in 2013. See some of his recent work in healthcare IT.

References
(1a) Spain train driver ‘on phone’ at time of deadly crash BBC News (30 July 2013)
(1b) Spanish train driver on phone to Renfe official at moment of crash, court says The Guardian (30 July 2013)
(1c) Spain Train Crash Hearing: ‘Driver On Phone’ Sky News (30 July 2013)
– though see also embedded article “Safety on Spain’s rail network” to the right of the main story which says that “The investigation into one of Spain’s most deadly rail crashes will undoubtedly focus on not only human error but also the safety mechanisms in place on the track.
(1d) Spain train crash: Video footage emerges showing moment train derails and kills 80, as police interview driver Francisco Jose Garzon Amo The Independent (25 July 2013)

(2) Paul Marks’ article in New Scientist considers the role of the ‘points’ at which trains move to a different part of the track: Track change at heart of Spain train crash inquiry New Scientist (31 July 2013)

See also
Driver in Spain Rail Crash Reportedly Was On Phone With Renfe (30 July 2013) California High Speed Rail Blog by Robert Cruickshank, and see the comments below that post.

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