Find The Pattern Behind A Points Failure
Apply 5 Whys to distinguish symptoms, causes, and controllable countermeasures after a repeated points failure.
Points 118 failed to detect normal three times between 06:10 and 08:20, causing 26 delay minutes and two platform changes. 5 Whys: symptom -> evidence-backed cause chain -> controllable countermeasure The common trap is stopping at old asset or operator error, which describes a problem but does not create a new control. Why 1 Why did trains lose time? Points 118 failed to detect normal during route setting. Start with the observable failure, not with a presumed department or person. Why 2 Why did detection fail? The switch movement was obstructed intermittently by ballast near the stretcher bar. This why…
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