alt Hacker NewsOnce upon a time I did root cause analysis professionally, and a trainer told us if you attributed the root cause to people without finding malice you were just being lazy. At the very least I doubt anyone to blame here was actually involved in the accident, but someone who decided it was not in the budget to put an automated system in place faster.
They had an automated system, it had failed earlier in the day in that section causing trains to be signalled to stop. Then they had a manual go-slow human backup protocol which appears to also have not been observed - some drivers were given clearance to continue as normal. Swiss cheese of compounded failures, with tragic results.