April 2, 2007 | Mark Paradies

Monday Accident and Lessons Learned: Root Cause Analysis is Essential … Network Rail Fined £4 Million for Paddington Rail Disaster

Here’s a quote from an article in the Gardian Unlimited in the UK:

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Officials from Railtrack, the precursor to Network Rail, were warned at least five years before the collision that a set of signals was badly laid out and so difficult for drivers to interpret that a serious incident was likely to happen, the hearing was told.

The signals had been misinterpreted by drivers at least seven times in the previous five years, and had been the subject of internal inquiries.

The Paddington disaster, which was likened in court to a “senseless and unnecessary terrorist attack”, would never have happened had it not been for a string of safety blunders.

Failures spanned several years and flowed from “the culture at the top” of the company, the court heard.

Passing sentence, Mr Justice Bean said Railtrack had admitted that its failure to carry out “adequate root cause analysis” of signals passed at danger (Spads) had been “systemic and unacceptable”.

Quoting from his judgment, he added: “It was due, as counsel to the [Lord Cullen] inquiry submitted, to a combination of incompetent management and inadequate process, the latter consisting in the absence of a process at a higher level for identifying whether those who were responsible for convening such committees were or were not doing so.

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What can you learn? That root cause analysis is essential for the safety of your passengers and employees in the transportation business. If your company has responsibility for the safety of your customers, you had better thoroughly investigate safety errors and near-misses (close calls).

To read the complete article, see:


Root Cause Analysis
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