At least the SOFA folks have figured something out - that accidents have multiple interwoven causes. Unfortunately they are still limiting their analysis to the bottom operational level and looking for a solution through more rules compliance and behavior modification of the victims.
Safety alert: Reducing switching accidents
CLEVELAND, April 22 -- The Switching Operations Fatality Analysis (SOFA) Group has issued its safety statistics for the month of January of 2004.
According to SOFA, there were 11 “severe injuries” in switching operations in January, including two amputations.
9:35:01 AM 
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