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swiftcoder • yesterday at 10:48 AM • 9 replies • view on HN

The level of human negligence here is astounding. The system did exactly what it was supposed to (lock the train down if the track can't be confirmed clear), and then a human controller ordered the crew to override the system, and ordered them to proceed at an unsafe speed towards a similarly disabled train?


Replies

dimal • yesterday at 6:48 PM

Usually when you look deeper at failures like this, it’s because there’s a morass of bad incentives from the surrounding human system that enforces this kind of behavior.

Here is a plausible alternative explanation:

They’ve probably seen false warnings over and over and overridden them enough times that they lost sense of the risk. They need to keep trains on schedule, using a buggy system, with a manager looking over their shoulder. They override the warnings over and over, nothing goes wrong, and they forget that it may actually be right. Look at the Challenger explosion, Chernobyl, or any other failure like this, and there’s usually a bureaucratic process that has run amok, and the individual is just following perverse incentives that have been socially normalized over time.

So I’ll wait until I have more information before I proclaim this as human negligence and the system doing exactly what it’s supposed to do. We don’t know how often it was doing the wrong thing and confusing the fuck out of the human.

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crote • yesterday at 11:21 AM

Whose negligence, though? "The system" isn't just the LZB equipment - the train dispatcher is just another cog inside the same system, and should be expected to occasionally fail just like every mechanical part.

This isn't a game of Hot Potato where the last person touching it goes to jail for gross negligence. You have to look at it through a Swiss Cheese model: every individual safety layer can and will have holes, but a disaster can only occur when all of those holes align.

Why did the LZB system fail? Why did the train dispatcher use the wrong backup procedure? Why did a backup procedure with zero safety checks even exist? Why did the train operator accept this backup procedure? Why did the train allow high-speed driving under those unsafe conditions?

It does indeed seem like the train dispatcher made a big mistake, but that was far from the only thing that went wrong, and it would be myopic to use him as the scapegoat for a far larger systemic issue.

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wjnc • yesterday at 11:02 AM

I would argue that we should look at systems-level explanations. The human factor is so glaring we can get caught up in it. There are what, 50?, high speed trains in movement in Spain at the same time. Even GPS + Starlink + 1 monitor (is that 50k€?) could have prevented this. But it happened, and the question is what is going on with train security in Spain in general for people to (be able to) make such decisions.

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thatfrenchguy • yesterday at 7:47 PM

They have a failsafe to use (visual) block backup signaling on that line and used it incorrectly. 200km/h is right at the border where you don’t need in cabin signaling.

cryptoegorophy • yesterday at 10:30 PM

oh man, the override thing is super dangerous. I use FSD in Tesla a lot and there is a lot of times I "override" with the gas pedal because I think it phantom breaks or being slow and there were at least 2 cases where there was legitimate reason to stop (person crossing in my blind spot).

tencentshill • yesterday at 5:55 PM

Too bad they don't run it with AI. Then it would be nobodies fault!

inglor_cz • yesterday at 7:56 PM

This really reminds you of the Chernobyl station computer printing all the warnings and recommendations to shut the reactor down when they started playing around with it ... and Comrade Dyatlov overriding it.

Dyatlovs seem to be born everywhere.

1718627440 • yesterday at 10:58 AM

Sorry, but ordering trains to drive manually after the system locks itself down, is the proper procedure. Of course you are still supposed to only send trains to free sections, but the error is in that step, not that they ordered a train to drive on it's own.

Also the fallback procedure is also aided by automatic systems and a sizable number of accidents in the past were caused by that information being faulty.

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masoudya • yesterday at 8:34 PM

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