By Kim Smiley

On March 4, 2012, two passenger trains collided head-on near Szczekociny, Poland killing 16 and injuring 58.  It was Poland’s deadliest train crash in 20 years.

An investigation is underway to determine what caused the deadly accident, but an initial Cause Map can be built now and more details can be added as information becomes available.  A Cause Map is a visual root cause analysis format.  The first step in the process is to determine which organizational goals were not met and in this example the obvious goal to focus on is the safety goal.

The safety goal wasn’t met because there were fatalities and injuries.  This occurred when two trains crashed because they were traveling on the same track in opposite directions.  It’s not clear exactly how the trains ended up on the same track, but it appears human error was involved since prosecutors have announced plans to charge a controller for unintentionally causing the accident.  Media reports have also stated that the routing mechanism for one of the trains was set incorrectly so that it was sent down the wrong track and into the path of the other train.  As with any investigation that leads to human error, more information will be needed about why the mistake was made in order to fully understand why the accident occurred and determine what would be needed to prevent a similar one in the future.  In this case, we can also assume that the accident was caused by inadequate oversight of the controller or lack of a double check of the mechanisms because an ideal system won’t allow one single mistake to result in a deadly accident.

Another fact worth considering is that the rail system in Poland is in the midst of a massive modernization effort.  Poland’s rail system is being modernized to prepare for the huge crowds expected to travel to the Euro 2012 soccer championship this July.  The modernization effort has been possible in part because of subsidies offered by the European Union, which Poland joined in 2004.  As part of the modernization, more connections have been added and more trains have been running on the track where the accident occurred.  It isn’t clear yet if any of the changes contributed to the accident, but any recent changes to a system are worth reviewing during an accident investigation.

As more information is found during the investigation, the causes can easily be incorporated into the Cause Map to capture as much detail as needed.  To view a high level Cause Map, click “download PDF” above.