What we know so far about Spain train crash
bbc.com198 points by ZeljkoS a day ago
198 points by ZeljkoS a day ago
The following is hypothetical, since we do not have a proper safety report yet.
It sounds like the issue happened, because there was an error in the line-based train control system (LZB), which led to falling back to the point-based train control system (ASFA). However since there are more virtual blocks in LZB, than physical blocks in ASFA, this means that suddenly more than one train is in one block, which violates the most basic assumption of train control. That requires the trains to not rely on the train control at all, even if it says that the block is clear, but instead are operated manually.
I do not know what the proper procedures for that are in Spain, but in e.g. Germany that seems to require driving by sight. However that is also only after a number of accidents due this situation. So the following seem to be similar accidents from Germany:
- https://de.wikipedia.org/wiki/Eisenbahnunfall_von_Meerbusch-...
- On April 9, 2002, a near-collision occurred near Fallersleben. After a computer at the LZB control center in Fallersleben crashed, two trains on each of the two main tracks came to a stop. When the computer was restarted, the rear train in each pair was signaled a speed of 160 km/h, while the front train in each pair was signaled 0 km/h. One of the two train operators following saw the train stopped in front of him; the other, as a precaution, contacted the operations center, which warned him not to proceed.
From reading only the linked BBC article, I would come to a totally different conclusion. That would sound like more of a dispatcher ordering a manual operation of a train, without having assessed the situation correctly. While yes, this happens (https://en.wikipedia.org/wiki/Bad_Aibling_rail_accident), this happens on minor single-track lines where the dispatcher starts playing games on his smartphone full-time due to being bored, not on a major high-speed line. Also the issue with LZB doesn't fit into the picture that the BBC paints, neither do the many people involved, so I will prefer the theory mentioned above. Also that seems like a "reasonable" "sufficiently not-obvious" error to make, given the line and attention.
So to explain the used terms more: Most train control systems operate under the assumption of a fixed block. The whole network is separated into blocks, there can always be only one train in a block. Each block is protected by a signal, there must always be a red signal separating one train from the next, and there are sensors that detect when a train drives in a block, when it drives out of a block and how many carriages (train integrity is important too).
For point based train control systems, operation of a train is only enforced at every signal (and on the way in approach at specific points), this means e.g. that a train does not run over a red signal, does not drive faster than the maximum speed, and has acknowledged speed limits.
For line based train control systems, that supervising happens continuously over the whole track.
Since the physical signals and sensors are expensive in installation and maintenance and railway capacity depends on the number of blocks on a track, line based train control systems support virtual blocks. This means that the signals and sensors are not physically there, but simulated by computers (on the train and signalbox). From the view of the point based train control that means multiple trains are in a single block, because it does not know about the virtual subblocks. When a train is running that only supports point based train control it can only use whole blocks, so the capacity is simply reduced, but it is still safe, because every physical block is also known in the line based control system.
When the line based train control system stops being in use, the fundamental constraint of the point based train control system is being violated: there are multiple trains that are in a single block, and hence not actually protected by a red signal in between. This means that you must ignore the signals until every train has crossed at least one physical signal.
(This is speculation:) It seems that that the operators assumed that there is still a safety system in place, that they can rely on. Hence they did no tell the trains to use manual operation, (which might also require driving by sight [max. 40km/h], but not necessarily, I don't know the proper procedure in Spain), but told them to fall back to the normal safety system. It's reported that some train drivers and dispatchers questioned that, but that can also be an translation error and instead them repeating what was said, as is proper safety procedure. But the point based train control system will show a green signal, even if there is actually a train in front, because it is in the same block as you, but the signal shows whether you are allowed to drive in the next block, not into the current, as you are already in the current block. This seemed to be what happened here, the second train saw the green signal thought they are back in the automatic safety system and accelerated to 200km/h, not knowing that there is still a train in front. The first train should have also started driving, but did not, due to an error in the train. In normal situations this should never cause an accident, but in this case the accident would not have occurred if that wouldn't have taken place, but that would have been simply by luck.
You can see the green signal in some of the pictures, which to me looks really weird (kinda like a both dead and alive corps), because I would expect to put all signals to red in the case of an accident. I would expect to do that, while you are calling the emergency number, but I do not know if that is the procedure in Spain. You also see in the pictures that the whole cluster traveled about a train length and that the last carriages of the first and the first of the second train are merged into one. This indicates a surprisingly high speed for the crash, above 100km/h. That fits the explanation of the second train not being able to see the first until directly up to a few 100 meters before.
There were actually more trains in that block, so it's pure luck, that there were "only" two trains involved in this accident. Also some claimed, that there was a curve directly before, so the second train couldn't see the first until directly up to the accident. This would not have prevented the accident, it would have just reduced the involved crash speed and hence reduced the number of dead people.
It's quite ironic, that the accident would have likely not happened in case of no safety system being present.
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Actual classical collisions of two trains like in this case are quite rare, because that's like the first purpose of every train control system, which exist since the 1870s. The accident from January this year in Spain was also a collision, but because a train derailed, while another train passed it. This can't really be prevented by a current train control system, other then not allowing the derailment to happen in the first place. Derailment in carriages is actually not rare at all, but daily, it's like going slightly on the shoulders of the street with your car, but train derailments are.
The accident from Meerbusch-Osterath from 2017 is similar in that is was also a collision. The cause itself is not really similar. The normal train control also failed, so the trains need to be operated manually. For that it was still relied on the automatic train detection and labeling system, but that had a bug (and some operator error due to a bug, this is simplified) and showed the number of the second train, where the block of the first train was. So they allowed the second train to advance. They did have contact with the first train, because they noticed something was wrong, but that driver didn't properly speak German and also failed to look out of the window directly where a hectometer sign was, so he couldn't tell the dispatchers were he actually was. The dispatcher forgot to tell the driver of the second train to use drive by sight (40km/h), so he accelerated to full speed (120km/h). The accident only caused 40 injured people and no deaths, because the second driver saw the first train. The accident happened at night, in the dark and at a speed of 85km/h. Train dispatchers are supposed to keep track of the trains and the actions they do too, but since the automatic train detection and labeling works most of the time, it becomes easy to rely on it.
The accident from Fallersleben from 2002 is similar, because the original failure of LZB and fallback to PZB is the same. Hence there was also more than one train in one block. The signalbox software told the second train to advance to full speed and the first to stop. This would have caused a crash, but the train driver of the second train noticed, that couldn't be and notified the dispatcher who then told them to not proceed, hence the accident didn't happen. This caused it to become mandatory to let the first train to drive again operate on sight [40 km/h].
> the signal shows whether you are allowed to drive in the next block, not into the current, as you are already in the current block. This seemed to be what happened here, the second train saw the green signal thought they are back in the automatic safety system and accelerated to 200km/h, not knowing that there is still a train in front.
Don't think the second train saw a green signal. They were in the middle of the block, while the first train was waiting just before the exit of the block (with a green signal ahead).
What I'm gathering from other sources is that the Spanish system allows the controller to override the point-based rules and provide manual clearance (because the blocks are long and it takes forever to reach the next signal by sight). It's a failure of the system imo. Ideally, the system, under no conditions whatsoever, should have even allowed such a practice to be allowed.
> The accident from January this year in Spain was also a collision, but because a train derailed, while another train passed it. This can't really be prevented by a current train control system, other then not allowing the derailment to happen in the first place.
Or by putting all the signals to red after the derailment of the first train so as to stop all the circulation on the line, which seems not to be the common practice in Spain unfortunately.
The first train going from A to B derailed, and the second train going from B to A crashed into the derailed cars 9 (20 on other sources) seconds later. Even if the second train was put in full brake in the exact same second the derailment happened, it couldn't have avoided the crash.
Surely a better fallback is possible. Like if a train is known to be in a PZB with other trains ahead of it, then when LZB goes down it has to slow down/wait/follow some different protocol until PZB rules can be enforced again.
The level of human negligence here is astounding. The system did exactly what it was supposed to (lock the train down if the track can't be confirmed clear), and then a human controller ordered the crew to override the system, and ordered them to proceed at an unsafe speed towards a similarly disabled train?
Usually when you look deeper at failures like this, it’s because there’s a morass of bad incentives from the surrounding human system that enforces this kind of behavior.
Here is a plausible alternative explanation:
They’ve probably seen false warnings over and over and overridden them enough times that they lost sense of the risk. They need to keep trains on schedule, using a buggy system, with a manager looking over their shoulder. They override the warnings over and over, nothing goes wrong, and they forget that it may actually be right. Look at the Challenger explosion, Chernobyl, or any other failure like this, and there’s usually a bureaucratic process that has run amok, and the individual is just following perverse incentives that have been socially normalized over time.
So I’ll wait until I have more information before I proclaim this as human negligence and the system doing exactly what it’s supposed to do. We don’t know how often it was doing the wrong thing and confusing the fuck out of the human.
"They need to keep trains on schedule, using a buggy system, with a manager looking over their shoulder."
Also lots of potentially angry passengers who want to get to their destination in time. Will miss important appointments, or even the last train connection for the day and be stranded if the train drivers decide to wait a little bit longer to be on the save side.
> "the individual is just following perverse incentives that have been socially normalized over time"
Normalization of deviance,
https://hn.algolia.com/?query=normalization%20deviance&type=...
Given this keeps happening in Spain, maybe we'll need to call this "Normalization of normalization of deviance".
Humans never learn.
I recently saw a doc on the 2013 Spanish crash and it was full of absurd system problems. The govt pinned it on the driver as best they could but it's clear that it was entirely preventable.
Jenga effectively. 3 others and Bob spent time destabilizing but Bob over here pulled the block before it collapsed. It's his fault.
It’s still gross negligence to place punctuality over safety, regardless of the reasons behind this behaviour.
(Un)Fortunately, finding someone who is "at fault" generally helps neither in investigating root causes nor in preventing similar problems in the future.
Usually it's detrimental, hence (criminal) investigations of personal liability in such cases are often only allowed after systemic investigation has concluded.
In court, you are allowed to withhold information that makes you look bad, which is simply lethally unhelpful when we want safer trains.
I don't mean to absolve people for negligence, but when margins are very small and paychecks may have become a necessity to survive on this planet, sometimes within the complex process the collective behaviour gets pretty weird.
There are not that many people who (care to) see the big picture(s) and the consequences their semi-small actions may have in the long run.
> human negligence and the system doing exactly what it’s supposed to do
Negligence is not limited to the single human who issued the order. it's pretty unlikely that their order could have caused this without a significant amount of other negligence that eroded the safeguards. Nevertheless, the negligence is human, not machine in nature.
Trains in spain have been running at reduced speed, delayed or even cancelled for a while due to aging infrastructure, which might've actually caused another deadly accident back in winter, so this behavior does not surprise me.
Normalization of deviance [0], wherein a clearly unsafe practice becomes considered normal if it does not immediately cause a catastrophe: "a long incubation period [before a final disaster] with early warning signs that were either misinterpreted, ignored or missed completely
Whose negligence, though? "The system" isn't just the LZB equipment - the train dispatcher is just another cog inside the same system, and should be expected to occasionally fail just like every mechanical part.
This isn't a game of Hot Potato where the last person touching it goes to jail for gross negligence. You have to look at it through a Swiss Cheese model: every individual safety layer can and will have holes, but a disaster can only occur when all of those holes align.
Why did the LZB system fail? Why did the train dispatcher use the wrong backup procedure? Why did a backup procedure with zero safety checks even exist? Why did the train operator accept this backup procedure? Why did the train allow high-speed driving under those unsafe conditions?
It does indeed seem like the train dispatcher made a big mistake, but that was far from the only thing that went wrong, and it would be myopic to use him as the scapegoat for a far larger systemic issue.
Sounds like you have internalized https://how.complexsystems.fail/ :-)
Overriding safety systems is itself a safety capability. But this wasn't a failure of the safety systems. It wasn't even a failure of the train drivers who had been over using safety system overrides. It was a management failure for not noticing that over use of overrides.
Also the train driver could have pushed back, in the radio recording with the dispatcher, he tells the driver to "proceed normally", the driver asks "proceed normally?" and the dispatcher confirms it. Here's were I would expect that better training or more availability of information to the driver would've made him push back on that decision.
Dispatcher, conductor at that time could not have know that dispatcher ordered manual bypass ignorig the rest of the guardrails of a traffic resume procedure
Not OP but I'm imagining we'd ask the question why the "dispatcher ordered manual bypass ignoring the rest of the guardrails". They're saying it's all slices of cheese in a system that failed here.
It seems that one of the train conductors did know that it was not the procedure and tried to warn of the problem.
why does the dispatcher even hold the right to override the automatic system by themselves? this should involve multiple people, at least a signoff by a superior.
The automatic system will fail at some points so manual dispatch is needed, which is how this all happened
Indeed the system is all of it - all gear on another level of abstraction where it as a whole is just enabling processes, not the thing running it.
If you ignore a road sign and run someone over in your car today, nobody will make systemic excuses for you.
Someone was driving the train who couldn't estimate the stopping distance relative to speed.
If a car is stalled in the middle of the road, and you hit it, that's on you. 200% if a reflective warning triangle was up 100 meters back.
Trains take a long time to stop even at moderate commuter train speeds because they are so heavy, let alone high speeds of 300km/h+.
At least one of the failures here is that the dispatcher authorized such a high speed, in other systems I am familiar with, generally the procedure with a signal fault is to crawl at a speed such that the train can stop in line of sight distances.
In fact, that is the Spanish protocol, which for some reason was bypassed by dispatch even after the train driver had questioned it:
> Under normal protocols, the driver would be expected to continue moving at a maximum of 40km/h according to their line of sight, and not at normal speed on a track designed for speeds of up to 200km/h.
If a stretch of road continues to have frequent crashes even though a sign is present, it is worth examining why that sign alone is not solving the issue.
Air travel is as safe as it is because we don't stop the investigation at "pilot error" but instead ask why the pilot made the mistake, and why a single mistake was able to lead to loss of life.
Yeah. This single accident was more deadly than all commercial air traffic in the EU in the past 10 years together, while 50 deaths per day is the average for car crashes in the EU. Wild orders of magnitude difference in safety.
Rough estimate: by car, you can travel from Lisbon to Talinn (4000km) 100,000 times before expecting to die; by train, almost 4 million times, by plane 400 million times.
And if you're the median person (not the average person), you can probably 3x those numbers, because such a large number of casualties in traffic are risk-seeking individuals (e.g. a drunk driver is included in "average person" but not in "median person")
I don't think trains are the same as cars. Trains are supposed to run at high speeds under normal circumstances and the system is supposed to keep everyone safe. It clearly said they wouldn't be able to drive over 40 km/h if they had to operate by line of sight.
Cars otoh don't have someone overseeing everything and directing traffic. They have to operate by sight.
I don't mean to pick, but it seems like you have near zero knowledge of how train systems work.
You are 100% dependent on your safety and monitoring systems because almost every problem that could come up is beyond the horizon of your human senses. Stopping distances are in thousands of feet to miles depending on the train size and weight. Add any curves and that's far beyond your visibility.
Then you add in management complaining that you're too slow and you need to do things faster and cheaper or you'll lose your job. Things turn from solution culture to blame culture.
Then you add in false errors and warnings in a system that teach you to ignore them and an upper management that doesn't fix them.
Then you have the day like hundreds of others where warnings are going off, management is yelling, but this time there is a stopped train around the corner and everyone dies.
This is a systemic problem.
I wish this were true, but there is basically no consequences for drivers in the situation you described. The most egregious example I can think of near me was in 2022 when a kid was crossing a flashing crosswalk with his bike near Tacoma, and truck had stopped to let him cross. A woman ignored the crosswalk signal and used the adjacent lane to drive past the stopped truck and hit the kid, killing him. The woman was never criminally charged. She didn't even experience any consequences for her driver's license.
https://komonews.com/news/local/13-year-old-boy-killed-while...
I think this is something about the incentive structure of the US legal system.
Here in Australia, a member of my family was involved in a fatal accident with a pedestrian, around 20 years ago. They put him on trial even though the case was weak, and then the prosecutor moved for dismissal part way through the trial. But, what people told us, is prosecutors are encouraged to take weak cases to trial because dropping the case part way through the trial is more politically palatable than refusing to bring it to court to begin with.
> Someone was driving the train who couldn't estimate the stopping distance relative to speed.
The stopping distance for a train this size and this fast is around 2km. Good luck estimating that by sight. There is a reason the normal protocol has a 40km/h max speed for traveling according to line of sight, which the driver was told wasn't needed.
Indeed, car crashes tend to just blame one (or more) of the drivers. Nobody excuses a foolish driver with systemic excuses.
On a surely unrelated note, car travel is by a substantial margin the most dangerous mode of transport most of us ever use, and the most dangerous activity most of us routinely engage in.
I would argue that we should look at systems-level explanations. The human factor is so glaring we can get caught up in it. There are what, 50?, high speed trains in movement in Spain at the same time. Even GPS + Starlink + 1 monitor (is that 50k€?) could have prevented this. But it happened, and the question is what is going on with train security in Spain in general for people to (be able to) make such decisions.
After learning about a sufficient number of such "accidents" I'm now convinced the cause is never "operator error", it's always a system error. It's the humans that design (or oversee their design and implementation of) those systems that are at fault.
"The cause", singular, shows you're not getting the the swiss cheese model still. Trying to find a singular cause is a big mistake which prevents other causes from being addressed.
Every hole in the cheese slices, including operator error, is important. And operator error is an important kind of error in particular, not because we need to prosecute somebody but because many forms of operator error can be mitigated using better system design, but you won't figure that out if you blind yourself to operator errors.
The current control system dates from the early 90s. They started rolling a modern system with more redundancies and automatic blocking in 2022 but it's still not fully deployed.
PZB is from 1934. Arguably always prioritizing deploying the most modern system on the highest profile lines, is what prevents us from properly rolling out the basic safety systems everywhere.
These high speed trains are pretty recent. Are we really not upgrading safety systems past the 1930's when upgrading a line from ~80kmph to ~300kmph?
I was only talking about the general problem domain, not about this specific location. The current safety system is also not was has caused this, likely. Or rather it has caused this by it's availability, not by it's safety.
PZB is only used up to 160 kph, and relies on wayside signals being read by operators. That's not possible on a high speed line. A more sophisticated signal system is simply necessary here.
According to the article, the track had LZB, though.
And according to the article the signalling system reported, that the track is blocked.
Trains are still not able to assess properly where they are, even using satellites and inside train sensors. Of course there is research on that, but it's still an unsolved problem. (Current alternative is to put markers in the track, but that's also expensive at scale.)
> Trains are still not able to assess properly where they are, even using satellites and inside train sensors. Of course there is research on that, but it's still an unsolved problem
Throwing up our hands about how hard a problem this is seems like a ridiculous position to stake. If we can design self-driving cars, that operate safely in far less controlled environments, we can figure out the linear offset of a large vehicle traveling along a physical rail running along a fixed pre-determined path.
> If we can design self-driving cars, that operate safely in far less controlled environments
Self-driving cars aren't supposed to drive quicker than they can look ahead, which makes the problem way easier because you don't have to figure out how to detect obstacles ahead of time and can simply rely on vehicle-local information to stop if necessary. And because cars can brake way more rapidly than trains, it means you can still drive reasonably quickly even within that limitation.
Plus in an emergency, cars have steering as an additional degree of freedom to attempt getting out of any nasty situation that may have developed.
(And of course the socially expected safety standards for cars are quite a bit lower than for public transport…)
Trains on the other hand have braking distances on the order of a kilometre or so, and high-speed trains at full speed several kilometres, so trying to get by on local data only is hopeless and the usual strategy is instead having central signalling system that can accurately track trains and coordinate their movements.
I said nothing about "throwing up out hands", this is a current research topic. But you can hardly blame the workers for not using a system, the researchers haven't invented yet.
> If we can design self-driving cars
We can not design self-driving cars to the safety standard that is required for railways. They are way less safe than the current half-manual system for railways. What you suggest is using less automatic safety systems than what we currently do.
Has there ever been a case where two self driving cars collide with each other? I hate to be part of the peanut gallery, but as a totally naive person when it comes to railway safety research it really does seem amazing train collisions can’t be easily prevented with gps, lasers, sonar or various other trivial ways. Even the crash in question seems like it might have been easily prevented by having a second human in the loop. Maybe I and others just suspect the difficulty isn’t so much technological as it is financial.
> Has there ever been a case where two self driving cars collide with each other?
I don't think that's relevant to trains. Cars can avoid a collision much more easily than trains can. Cars can swerve, and if they are at a distance at which line of sight tells them they will hit an obstacle, they are moving slow enough to stop before hitting that obstacle. Trains have to stay on tracks, and they need up to 4 kilometers to stop moving.
The constraints are very different, so the solutions and tradeoffs will be different too.
As far as I am aware, there has been no non-supervised train in a general train network. (They exist in closed systems.) However whether the train is self-driving is really not the issue here. In current railway safety systems (even from the 80s) a crash is about the same probability as random bitflips. However reality is too messy, so that the availability is not satisfactory enough to not use a human fallback, and then you are back to the assisted human error rate.
Current operation of a train is basically self-driving and supervising driver. So if you suggest "just use self-driving", you make the system less safe, not more, because it means just getting rid of the human supervisor. This is not currently done, because it would be too insecure. It might be done in the future, but rather because less safety is going to be accepted in favor for getting rid of the costly human.
A self-driving train will happily cause a crash, if the target is "drive with high-speed in that segment currently occupied by another train". The issue is that that becomes a target, not that there is a human in the loop.
> A self-driving train will happily cause a crash, if the target is "drive with high-speed in that segment currently occupied by another train".
Sure, if you allow trains to ignore safety completely, then accidents will occur. That is a ridiculous statement.
Yes, if the dispatcher issues faulty movement authorities, it's futile to look for the error in the train. That was my point.
Why is it that these fatal train accidents have happened multiple times in Spain, but never in Japan, even though Japan has been doing it high speed rail longer, and at 10x the passenger volume than Spain? Do they have some alien safety technology unavailable to Spain?
The were several other train accidents, where it was found out, that the drivers have made races, who can stay above the speed limit longer. But I think that was already in the 90s. There is/was definitely something at fault with the safety culture.
But there was a recent incident in Germany as well (https://en.wikipedia.org/wiki/Burgrain_train_derailment), which is somewhat similar to the earlier accident in Spain this year. Targeting high value projects, while not paying for proper maintenance is not something that only happens in a single country.
There were two fatal train accidents in the UK this year, one of them being a rear-end collision, despite no one even citing them in this thread, and definitely not claiming the UK having low safety culture. Sadly the Spanish "black legend" is still very much in force, portraying Spain as some lower place than it actually is.
Yes, you can say that high-speed rail crashes are not limited to one country (though Spain has had multiple this year alone), but you can't say that it has ever happened in Japan. So for you to argue up and down this thread that everyone calling out issues with Spanish high speed rail safety is wrong, as if it is some sort of intractable problem, is bananas.
I have not stated anything that is specific to Spain in this thread? I do think there is something wrong with the safety culture in Spain, I mean obviously, there was an accident.
> but you can't say that it has ever happened in Japan.
That sounds very unlikely to me, and in fact Wikipedia indicates otherwise: https://en.wikipedia.org/wiki/Shigaraki_train_disaster