Outline

What Problem(s) Train derailed, 78 killed, 130+ injured

Train Derailment Kills 79 in Spain

Santiago de Compostela, Spain
When Date
Time
07/24/13
8:40 PM
Differences ??
July 24, 2013
Where Physical Location Track near Santiago de Compostela
Impact to the Goals
On July 24, 2013, a train carrying 247 people Safety 78 killed, 130+ injured
violently derailed near Santiago de Compostela
Material Train destroyed
Spain. Over 130 were injured and 79 were killed as
a result of the accident. Many details are still Labor Massive emergency response/investigation
unknown, but investigators have determined that Customer Service Negative publicity for train company
the train was traveling about twice the posted
Schedule Train schedule significantly impacted
speed over a curved section of track.
This incident ??

High Level Cause Map

Train was
Distracted/ on
traveling at high High speed train phone
speeds
Train schedule
Schedule Goal
significantly Evidence: Train
Impacted AND
impacted Photo by wikipedia user Xosema. driver stated he was
Massive on phone with
Posted speed Sharp curve in train's ticket
emergency
247 people were was slower for this portion of inspector.
response/
onboard the Passenger train this portion of track
Train was
train traveling faster AND
Labor Goal
Impacted than posted Train operator Operator Automatic
Evidence: Train speed failed to take unaware of warning came
Safety Goal 79 killed, 130+ company records. action too late?
Evidence: The change in posted
Impacted injured train's data recorder AND
showed that it was Evidence: Operator Evidence: Accident
AND was familiar with still occurred despite
Evidence: Findings traveling at about
of investigators. twice the posted this portion of the the warning.
speed limit of 80 km track.
Major train crash Train derailed per hour.
Customer Negative AND
Major train crash
Service Goal publicity for
Impacted Evidence: Eye AND
train company Missed transition
witness accounts. Train failed to
Video of accident. slow down Automatic to zone requiring
Evidence: Articles
about the accident in system only operator to
major newspapers. AND warned driver of

AND
Material Goal Operator action Automatic Train had left
Train destroyed
Impacted required to slow system was not track where it was
train controlling controlled
Evidence: Photos Train was
Geography of
from crash site. traveling curved AND
area
For a free copy of our Root Cause Analysis Template in Microsoft section of track Different system Track shared
Excel, used to create this page, visit our web site.
installed than on with
Why other high speed
track
conventional
trains
The initial investigation findings have led to the train’s driver
Evidence: The European Rail Traffic
Effect Cause being provisionally charged with multiple counts of homicide Management System automatically
Investigate Problems. Prevent Problems.
Houston, Texas 281-412-7766 ThinkReliability.com
by professional recklessness on 28 July 2013. controls braking and is installed on
most of the high-speed track in the
NOTE: Read the Cause Map from left to right
area, but not in area where the
with the phrase "Was Caused By" in place of accident occurred.
Copyright ThinkReliability 2013 each arrow.