last good country

On today’s NTSB hearing

I don’t expect any big surprises today, though I do wish I was in town for the hearing. I’m in Stockholm until Sunday, but I’ll be following the developments.

I expect the probable cause to be a failure in the automatic train control system, the specifics being interference introduced by a defect in a wee-z bond. This resulted in the block of track appearing as though it was unoccupied. I’ve heard rumors this may have been caused by replacing a component with a non-recommended part. There was work done on that circuit prior to the crash, and problems had been detected beforehand. The NTSB will also likely comment on the fact that the seriousness of the crash was amplified by the less-crashworthy series 1000 cars. Also, there is still a lack of a backup ATC system, though Metro is working on this.

The only surprises may be with regard to how much Metro knew (or didn’t know) about any circuit problems in the area prior to the crash. I fully expect to hear that some Metro employees were aware, but that the safety culture is such that the problems were not addressed in a timely manner. I expect that a good deal of blame will be placed on management. I think we will have a better understanding of why John Catoe “unexpectedly” resigned earlier this year. While I doubt he was personally to blame, I have no doubt that failed leadership significantly contributed to a work atmosphere that permitted this tragedy to occur. As with most failures of complex systems, there is rarely one simple cause. Rather, it is a combination of failures, across many subsystems that snowball to cause catastrophe.