Monday, 26 January 2015

Kings Cross,Trains and a Swiss Cheese

New Year's Resolution: write more .... and .... 26 days later....finally got around to it. So after a prolonged break and spending most of it reading upon topics from organizational failures, safety, privacy and a touch of homomorphic encryption, I came around this:

which is an exceptionally well written summary of the problems at King's Cross Railway Station after Christmas 2014 where overrunning engineering works blocked all long distance and commuter rail services out of one of the London busiest termini.

What actually started out as a fantastic opportunity to perform engineering work over a rare, four day holiday became the proverbial nightmare as works overran by 24 hours. As a relatively simple study in the Swiss Cheese model it provides a wealth of issues and examples of how the holes in the Swiss Cheese lined up as a large number of minor problems coalesced into a "disaster".

Despite meticulous planning and well rehearsed contingency and emergency plans, and even pre-emptive measures such as providing extra machinery and fitters to correct problems on-site it eventually came down to a lack of drivers for freight trains that finally provided the final hole in the Safety Swiss Cheese.

An excellent example of how things go wrong despite detailed planning. Of course it is easy to judge with 20/20 hindsight and see clearly that a number of known failure points were obvious, but like many of these cases at each point the situational awareness was for many reasons lacking. Funny how the same aspects occur here in engineering as well as medicine, aviation and of course privacy.