By Kim Smiley

It is rare for the conduct of the investigation to be one of the biggest headlines in the week following an accident, but this has been the case after a recent train crash in China.  On July 23, 2011, two trains collided in Wenzhou, China, killing 39 and sending another 192 people to the hospital.

What appears to have happened is that a train moving at speed rear ended another train that had stalled on the tracks. It was announced that the first train had stalled after a lightning strike.  Soon after the accident, people reported seeing the damaged train cars broken apart by back hoes and buried.  Meaning the evidence was literally being buried without ever having been thoroughly examined.  The Chinese government stated that the cars contained “State-level” technology and were being buried to keep it safe.

The internet frenzy and public outrage fueled by how this investigation was handled was impressive. According to a recent New York Times article, 26 million messages about the tragedy have been posted on China’s popular twitter-like microblogs.  So powerful has the public outrage been that the first car from the oncoming train has been dug up and sent to Wenzhou for analysis.

More information  on the technical reasons for the train crash is slowly coming to light.  Five days after the accident, government officials have stated that a signal which would have stopped the moving train failed to turn red and the error wasn’t noticed by workers.  There is talk about system design errors and inadequate training.

It’s unlikely that all the details will ever be public knowledge, but there is one takeaway from this accident that can be applied to any organization in any industry that performs investigations – the importance of transparency. The Chinese government spent over $100 billion in 2010 expanding the high speed rail system, but if people don’t feel safe riding the rail system it won’t be money well spent.  Customers need to feel that an adequate investigation has been performed following an accident or they won’t use the products produced by the company.

To view an initial Cause Map built for this train accident, please click on “Download PDF” above.  A Cause Map is an intuitive, visual method of performing a root cause analysis.  One of the benefits of a Cause Map is that it’s easily understood and can help improve the transparency of an investigation for all involved.