‘Colossal’ mistake in Amtrak crash? Human Error Again?

Posted by on Apr 5, 2016 in Systems Thinking | 0 comments

trainChester, Pennsylvania (CNN) 

By Holly Yan and David Shortell, CNN, Updated 1:07 PM ET, Tue April 5, 2016

Strong evidence suggests two Amtrak construction workers killed in a train crash made a “colossal” mistake by being on the wrong line, a source close to the investigation said Monday.

The crash occurred Sunday morning when an Amtrak train carrying 341 people slammed into a backhoe on the track near Philadelphia, killing the two construction workers.

Another 37 people were injured and treated for minor injuries, a Chester city spokeswoman said.

Investigators will try to determine why the construction workers may have been on the wrong line, which was considered “active,” the source said.

Every time that there is a huge accident, authorities blame it on “Human Error”!  They are blaming the people instead of the “Management System” which allowed the error to occur in the first place! I would bet that other people in the company will say that they saw this coming.

“They should have known better than to be on that track,” Zarembski said. “Maybe what happened was they were given permission to go on (an inactive) track, and maybe they made a mistake and went on the wrong track.”


This is a very tragic accident which resulted in two workers losing their lives. There are some basic quality tools that have been around for 50 years such as the Failure Mode Effects Analysis  and the Deming Theory of Profound Knowledge that management should be utilizing to reduce the risk of these events from occurring.  These tools identify risk, severity, likelihood of occurrence and the controls to prevent a problem from happening in addition looking at the systems and human psychology.


It’s time that our media start asking the RIGHT questions and ask for improvement to the “Management Systems” that cause these events. This is not a People problem, it is a Management Problem!

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