Friday's tragic Metrolink crash in Chatsworth, which killed 25 people, was not the only fatal rail accident last week. Less than an hour after the Chatsworth crash, a car was struck by a Metrolink train in Corona and the driver killed in a grade-crossing accident.
According to the Federal Railroad Administration, 74 people have died in Metrolink crashes since 1999 in California. And in a total of 821 accidents, 90 people have died on the Metropolitan Transportation Authority's L.A.-Long Beach Blue Line from its inception in July 1990 to July 2008.
The root cause of most of these accidents is attributed to human error. But is this carnage always caused by train engineer error, or drivers trying to beat the train, or inattentive pedestrians trespassing on tracks? Flatly attributing accidents to just the actions of front-line operators -- or drivers -- is an oversimplification of the problem. Are we to believe, for instance, that all crossing incidents were because of negligence when the death rate is so much higher here than almost any other place in the nation?
What James Reason, a psychology professor at Britain's Manchester University and the author of the book, "Human Error," points out about many technological systems failures could also characterize last week's crash:
"Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking."
At USC, 25 years of research into the safety of technological systems bears this out. It has shown that on many occasions, the error and its consequences are the result of a multitude of factors, including poor workstation and workplace designs, complicated operational processes, unreasonable mental and/or physical workloads and inadequate staffing, faulty maintenance, ineffective training, nonresponsive managerial systems, dysfunctional organizational structures and haphazard response systems.
For example, rail-crossing accidents could be attributed to a combination of human and technological problems, including design or system-induced errors, the design of an intersection, confusing and limited warning signs, dim and insufficient warning lights and inadequate gates. The size of a crossing may not allow for sufficient time to clear the way before the arrival of a 79-mph train. These poorly designed systems then lead to driver error or train engineer error.
