Train Crash Kills 39 by niusheng11


									                                                                                                                                          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
   Train Crash Kills 39                                                                                                                   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
   Wenzhou, China                                                                                                                         hospital.
                                                                                                               Train cars
   July 23, 2011                                                                                             contain "state
                                                                                                                                          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
                                                                                                           level" technology
                                                                                                                                          the first train had stalled after a lightning strike. Soon after the accident, people reported seeing the damaged train cars broken apart by
                                                                                                       Evidence: Statements by            back hoes and buried. Meaning the evidence was literally being buried without ever having been thoroughly examined. The Chinese
                                                                                                       Chinese government,                government stated that the cars contained "State-level" technology and were being buried to keep it safe.
                                                                                                       patents are being sought
                                                                                                       for improvements in                The internet frenzy and public outrage fueled by how this investigation was handled was impressive. According to a recent New York Times
                                                                                                       existing technology                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.
                                                           Belief the
                              Public outraged                                    Trains initially                                         More information on the technical reasons for the train crash is slowly coming to light. Five days after the accident, government officials
   Cust. Service                                       evidence wasn't                                         AND
                               by handing of                                    buried within two                                         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
   Goal Impacted                                           properly
                               investigation                                     days of crash                                            about system design errors and inadequate training.
                        Evidence: Bloggers and                               Evidence: Eye                 Desire to protect
                        journalists world wide                               witness accounts,             technology from
                        have written about                                   Chinese government                 theft?
                        outrageous handling of                               acknowledged the
                        investigation.                                       burial                      Evidence: Statements
                                                                                                         by Chinese                                       First train stalled         Train struck by
                                                                                                         government                                           on tracks                  lighting?

                                                                                                                                                                                Evidence: Statements by
It’s unlikely that all the details behind what caused this crash will ever                                                                                                      Chinese government
                                                                                                              Trains cars
be public knowledge, but there is one takeaway from this accident                                                                                                               soon after the 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                                                                                                AND
speed rail system, but if people don’t feel safe riding the rail system
                                                                                                                                     Two trains
it won’t be money well spent. Customers need to feel that an
                                                                                                                                      collided                                         Second train
adequate investigation has been performed following an accident or
they won’t use the products produced by the company.                              Safety Goal                39 killed, 192                                                          following normal
                                                                                   Impacted                     injured           Evidence:                                               schedule           No one informed
                                                                                                                                                                                                                                           Workers didn't
                                                                                                                                  Physical evidence                                                           second train of                                               Inadequate
                                                                                                                                                                                                                                          notice the failed
                                                                                                                                  of train accident,         Second train                                       first train's                                                 training
                                                                                                         Evidence:                                                                      AND                                                    signal
                                                                                                                                  eye witness             traveling on same                                       location
                                                                                                                                  accounts                       track                                                                                                 Evidence: Statement
                                                                                                         provided by State-
                                                                                                         run media                                                                    Second train                                                                     by Chinese
                                                                                                                                                                                    unaware that first                                                                 government
                                                                                                                                                                                       train stalled               AND
                                                         Production-                                         Clean up and
                                                                                 Train schedule
                                                        Schedule Goal                                        investigation                                                                                                                                                       ?
                                                          Impacted                                            performed

                                                                                                                                                                                                              Signal failed to             Design flaw in                      AND
                                                                                                                                                                                                                 change?                     system?
                                                                                                                                                                                                                                                                            design and
                                                                                                                                                                                                         Evidence: The Beijing          Evidence: Statement
                                                                                                                                                                                                         National Railway               by Chinese
          Cause Map                                                                                                                                                                                      Research & Design              government 5 days
                                                                                                                                                                                                         Institute of Signals and       after accident                 Evidence: The fast
          High Level                                                                                                                                                                                                                                                   rail system is rapidly
                                                                                                                                                                                                         Communications stated in       occurred
                                                                                                                                                                                                         a report that a signal on                                     expanding in China,
                                                                                                    Why?                                                                                                 the track failed to turn red                                  Over $100 b billion
                                                                                                                                                                                                         when the first train stalled                                  invested in 2010
            Houston Office 281-489-2904
                                                                                        Effect             Cause                                                                                         and the staff failed to
                                                                                                                                                                                                         notice the signal error

                                                                             NOTE: Read the Cause Map from left to right
             Copyright ThinkReliability 2011                                 with the phrase "Was Caused By" in place of

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