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Article in question: http://www.theguardian.com/world/2016/feb/16/german-prosecutors-believe-human-error-caused-bavaria-train-crash

Prosecution is quick to blame the operator for a “terrible human error”. And yes, this is certainly a terrible tragedy. But do we know enough to confidently conclude that human error was truly the cause of the crash (surely it’s not the only cause), and that the operator ought to be heavily punished? Perhaps that is the correct outcome, but we need to know why the error occurred, and why the systems in place allowed for the error to occur. From the sound of it, the operator realized his mistake and frantically tried to stop the trains. Will punishing him prevent a similar crash from occurring in the future? 

Two main dangers of stopping the investigation at the human error cause:

The underlying systemic problem(s) will go unaddressed, leaving the same non-transitory environment in place that will allow a repeat of this same event, and
It leads to punitive solutions, just as in this case where the dispatcher is potentially facing a 5-year prison sentence. Punishing the dispatcher is not the right solution (unless there is proven negligence or intent) and will do nothing to prevent recurrence. It will also make it harder to attract future job applicants.
What are your thoughts?

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RCA & FMEA TRAINING

Root Cause Analysis and Failure Modes & Effects Analysis training by Sologic provides the tools, skills, and knowledge necessary to solve complex problems and manage risk in any sector, within any discipline, and of any scale.
Learn More
 

SOFTWARE

Sologic’s cloud-based Causelink has the right software product for you and your organization. Choose from Individual, Team, or Enterprise.
Learn More