By Kim Smiley
On the morning of January 14, 2015, a prison bus went off an overpass and collided with a moving freight train. Ten were killed and five more injured. Investigators believe the accident was weather-related.
This tragic accident can be analyzed by building a Cause Map, a visual root cause analysis. A Cause Map visually lays out the cause-and-effect relationships to show all the causes (not just a single root cause) that contributed to an accident. The first step in the Cause Mapping method is to determine how the incident impacted the overall organizational goals. Typically, more than one goal needs to be considered. Clearly the safety goal was impacted because of the deaths and injuries. The property goal is impacted because of the damage to both the bus and train (two train cars carrying UPS packages were damaged). The schedule goal is impacted because of the delays in the train schedule and the impact on vehicle traffic.
The Cause Map itself is built by starting at one of the impacted goals and asking “why” questions. So why were there fatalities and injuries? This occurred because there were 15 people on a bus and the bus collided with a train. The bus was traveling between two prison facilities and drove over an overpass. While on the overpass, the bus hit a patch of ice and slid off the road, falling onto a moving freight train that was passing under the roadway. No one onboard the train was injured and the train did not derail, but it was significantly damaged. The bus was severely damaged.
The prisoners onboard the bus were not wearing seat belts, as is typical on many buses. They were also handcuffed together, although it’s difficult to say how much this contributed to the injuries and fatalities.
Useful solutions to prevent these types of accidents can be tricky. The prison system may want to review how they evaluate road conditions prior to transporting prisoners. This accident occurred early in the morning and waiting until later in the day when temperatures had increased may have reduced the risk of a bus accident. Transportation officials may also want to look at how roads, especially overpasses, are treated in freezing weather to see if additional efforts are warranted.
To view a high level Cause Map of this accident, click on “Download PDF” above.
You can also read our previous blogs to learn more about other train collisions: