A little while ago we shared the story of the Irish Rail train that left the platform at the correct time but somehow forgot 300 passengers, and left with just one visually impaired passenger.

From a reliable source we have recently learned of the findings of the investigation into what happened. It is a salutory lesson in the importance of processes, and the importance of controls and checks on processes.

The normal practice for the Irish Rail service is for passengers requiring assistance in boarding to be boarded last.  Due to some minor operational issues on the platform that evening, it seems that a controller took the decision to have the visually impaired passenger boarded before the other passengers – reversing the normal run of the process.

The guard on the train, having satisfied himself that the visually impaired passenger had been boarded safely proceeded to give the signal for the train to leave – on the assumption that if the last passenger had boarded it was time to go. It would seem that at no time did the presence of 300 people on the platform and the absence of people on the train register with the guard or the controller, so the train left.

A simple process short-cut, taken for a doubtless sound operational reason, gave information to the guard which, in his view of the process, meant it was time to go. At the risk of a bad pun we could say that ‘tunnel’ vision set in. Any number of small checks (such as a random check on carriages to see if there were any people in them) might have prevented the embarrassing problem.

The 300 passengers were accommodated on a different train which made an unscheduled stop on its route to connect with a special shuttle service that was laid on to bring the passengers to their destination. Efficient scrap and rework.

Our source also informs us that the revenue control ticket check statistics for the train that left the passengers behind showed 100% compliance that evening.