Focus Taiwan
Date: 2018/11/26
By: Lee Hsin-Yin

CNA file photo

Taipei, Nov. 26 (CNA) A series of mechanical malfunctions on a Puyuma express train and the poor troubleshooting capability of both the train driver and the Taiwan Railways Administration (TRA) dispatch control room are to blame for a deadly crash last month, a Cabinet investigation task force said Monday.

In addition, the TRA’s failure to establish and implement standard operation procedures (SOP) also indirectly contributed to the tragedy, said Allen Hu (胡湘麟), head of the Bureau of High Speed Rail, who is executive secretary and spokesman for the task force.

Citing the “Swiss cheese model,” which is often used to determine the cause of an accident, Hu said the crash was the result of an accumulation of human errors, ranging from train delivery checks to follow-up maintenance work and operational issues.

Under the model, an accident takes place only when multiple layers of risks — like holes on slices of cheese — are not blocked but align. At that point hazards go unchecked and lead to failure.    [FULL  STORY]