Causes of disaster: problems of coordination

What follows is a portion of my (as yet unfinished) thesis:

Recent literature has focused on several aspects of disaster management. Bier (2006) proposed that a major cause of the debacles following hurricane Katrina was due to “problems of coordination … between multiple organizations and multiple levels of government” (emphasis in original). She goes on to say that these coordination problems arose from combinations of miscommunication and differences in assumptions regarding who was responsible for what. The systems involved in anticipating and reacting to a disaster on the magnitude of Katrina are many and complex, but a train vs school bus accident that occurred near Chicago, Illinois, provides a similar, albeit smaller example of a disaster caused or exacerbated by a failure of coordination between agencies, though individual agencies may have performed their own functions correctly.

On 25 October, 1995, a school bus approached a paired railroad crossing and traffic-light-controlled street intersection. In order to trigger a green light, the bus had to proceed over the tracks, to the short strip of pavement between the railroad tracks and the street intersection. The length of this strip of pavement was such that, although there were no other vehicles between the school bus and the intersection, the rear of the bus extended into the railroad right-of-way as the bus waited for a green light.

On the approach of an express train, a railroad sensor sent a signal to the railroad cross bucks, which flashed; and gates, which closed, striking the bus as they did so; and to the traffic light, prompting it to halt crossing vehicular traffic in preparation for giving the bus a green light. After the light turned green, but before the bus driver had a chance to react, the train struck the bus’s rear with enough force to rip the bus’s body from its chassis. Five children died. Several more were injured.

Several factors contributed to this collision. For one, the amount of warning (approximately 25 seconds, on the day of the collision) provided by the railroad to the traffic signals became lost in translation between the railroad and the traffic engineers; the traffic engineers believed that the time between their system’s receiving the ‘train approaching’ signal from the railroad and the arrival of the train was longer than it in fact was. This was exacerbated by accumulated changes in the layout of the associated streets, which decreased the distance between the roadway and the railroad crossing. Before these changes, a school bus could safely fit between the crossing and the intersection. After these changes, it could not. The programming of the street traffic signals also changed. These changes were not communicated to the bus company or the railroad. Changes were also made in the railroad’s signaling procedures, including the amount of warning provided by the ‘train approaching’ signal they provided to the traffic signal, but these changes were not communicated to the highway engineers. All of these changes and the lack of clear communication regarding them combined to place a stopped school bus on the tracks, and to give that bus inadequate time to clear the tracks before the arrival of an express train.

Prior to the accident, traffic engineers received several complaints that the traffic signals failed to give traffic adequate time to clear the railroad tracks before the arrival of a train at the crossing, though no collisions resulted. Each time, the engineers checked the functioning of their system by comparing it to its designated programming, and found that the traffic signal properly did what it had been programmed to do. Similar tests by the railroad indicated that the railroad’s circuitry and signaling functioned properly and did what they had been programmed to do. At no time prior to the morning of the accident* did anyone evaluate the system as a whole, or evaluate it in terms of meeting the ultimate need of clearing vehicular traffic, under all weather and traffic conditions, from the crossing in advance of a train’s arrival. Additional factors contributed to this collision, but the fact remains that poor coordination between highway and railroad engineers led to the deaths of five school children, and to the injury of several more.** {{124 National Transportation Safety Board 1996;}} When this type of poor coordination is multiplied by multiple additional agencies, the possibilities for missed opportunities in mitigation and response can only be expected to increase.
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* On the morning of the accident, a traffic engineer was observing the combined rail and street intersection, on the possibility that heavy rush hour traffic might elucidate a problem where previous investigations had not. During this observation, the engineer witnessed the collision. {{124 National Transportation Safety Board 1996;}}
** The crew and passengers of the involved train were uninjured. The bus driver suffered minor injuries. {{124 National Transportation Safety Board 1996;}}