Cumbrian Train Crash—Poor IQ Management implicated
According to a report in the Guardian of 2007-08-27 the Cumbrian rail crash in Febuary 2007 that killed one person and injured many others had an Information Quality component which was the final link in the causal chain:
Alongside concerns over the points, the study’s focus will be a breakdown in communications among Network Rail’s Cumbria workforce which contributed directly to the crash. It is expected to state that track inspections were not carried out as planned, that records of inspections were flawed and that safety certification used by some engineers had expired.
Industry sources also confirmed reports yesterday that two different inspection teams thought the other had inspected the points prior to the crash and therefore failed to inspect a crucial stretch of track at Grayrigg. As a result, a Virgin Pendolino train travelling from London to Glasgow on the night of February 23 was derailed by a broken set of points that should have been noticed earlier by track inspection teams.
There are at least three information management issues here:
- The maintenance of inspection logs
- the maintenance of staff certification information
- training of staff in the importance of information and its use
The cost of the rescue effort was huge as was the cost to the NHS, the managers and maitnenance workers stand lose their bonuses and one person has been arrested. so once again we can see that Poor Information Quality can:
- kill
- cost huge sums of public money
- send people to prison
- hit individuals in the pocket
Oh… a trainwreck IQ trainwreck. Somewhat recursive, which makes me feel a bit guilty about this website’s title.
But it does focus the attention on the failure of information within a process.
The question I would pose is what was the root cause for the inspection teams each thinking someone else had done the job? Was there a history of timeliness issues in updating the logs?