ABSTRACT
This chapter obtains some additional information on the decision processes related to the accident through discussions with persons who worked in the Norwegian State Railways or the National Railway Administration, from the report of the accident commission of the National Railway Administration. It shows how the Røros line became vulnerable to human and technical errors as a consequence of management efforts to meet demands on performance and efficiency in an organization with insufficient capacity to follow up and implement its own decisions, and in the absence of strong watchdogs defending safety interests. The chapter summarizes relevant findings in the report of the public commission, and identifies features of the decision processes that may have contributed to the evolution of vulnerability on the Røros line. It tries to reframe these findings in order to examine how normal organizational processes can contribute to the evolution of vulnerability.
