MIDLAND -- The National Transportation Safety Board has found probable cause in the November train tragedy which left four people dead.
They say the fault lies "with the city of Midland and the parade organizer because of a failure to identify risks associated with the parade through a highway railroad crossing."
A member of the N.T.S.B. remarked that this was quote "a perfect storm of adverse circumstances."
The board didn't place the blame on one specific individual, but they did say the tragedy could have been prevented with proper planning.
The finger can now be pointed at the city of Midland, along with the organizers of the parade.
The N.T.S.B. says the city of Midland and the parade organizer of the Show of Support , failed to comply with city, state, and federal guidelines for road closures.
But Robert Sumwalt, vice chairman of the N.T.S.B., says this isn't uncommon.
"Organizations have procedures, but they don't follow them," Sumwalt said.
Sumwalt says the lack of safety regulations along with the "lax and informal manner by which the parade was organized, approved and executed," ultimately contributed to the disaster.
"I lecture about that, about the importance of having procedures and then making sure that you're following them. And then the third step of that is having a process in place that you audit to make sure you are in fact following those procedures," Sumwalt said.
The board also said that the nature of a parade, very slow and deliberate, with law enforcement escorts, led the driver of the parade float, Dale Hayden, to rely on the officers to take him and the float safely through the parade route.
"In doing so, that expectancy is created that his law enforcement escort is now doing that for him," Dennis Collins said. Collins is a senior accident investigator for the N.T.S.B.
Because of that perceived security, Collins says, when Hayden got to the railroad crossing, his focus was on keeping those riding on the float secure in their seats while traveling over the tracks.
"The comfort and non jostling of the passengers and not having them be ejected or moved from the float, becomes more safety critical in his mind," Collins said.
On average, 23 trains pass over that crossing ever day, and the board says future parade organizers and the city have the responsibility to avoid dangerous situations.
The N.T.S.B. says there are things that can be done besides having a safety plan in place to prevent accidents like this in the future. Among them, alerting the train companies that there is a parade coming through, which wasn't done in this case.
This is the raw transcript of the suggestions the N.T.S.B. made to prevent future accidents:
AS RESULT OF THIS RECOMMENDATION, THE STAFF PROPOSES SIX NEW SAFETY RECOMMENDATIONS. NUMBER ONE, TO THE FEDERAL HIGHWAY ADMINISTRATION, WORK WITH THE FEDERAL RAILROAD ADMINISTRATION TO INCLUDE GUIDANCE AND THE MANUAL AND UNIFORM CONTROL DEVICES FOR THE INSTALLATION OF ADVANCED WARNING DEVICES, SUCH AS MOVEMENT ACTIVATED LINK OUT SIGNS THAT SPECIFICALLY USE THE WORD TRAINED TO INDICATE THE PREEMPTION OF HIGHWAY TRAFFIC SIGNALS BY AN APPROACHING TRAIN. TWO, AMEND TO INDICATE PREEMPTION CONFIRMATION LIGHTS HAVE NOT INTENDED TO PROVIDE GUIDANCE TO THE GENERAL PUBLIC, WOULD BE USEFUL IN PROVIDING ADVANCED INFORMATION ON TRADE MOVEMENTS -- TRAIN MOVEMENTS. THE SECOND RECOMMENDATION WOULD BE ESSENTIALLY A COMPANION TO THE FEDERAL RAILROAD ADMINISTRATION. RECOMMENDATION NUMBER THREE, TO THE CITY OF MIDLAND, INCLUDED IN THE CITY ORDINANCES A REQUIREMENT THAT ALL ORGANIZATIONS CREATE A SAFETY PLAN AS PART OF THE CITY EVENT AND PARADE APPROVAL PROCESS TO INCLUDE THE FOLLOWING ELEMENTS -- ROUTE SELECTION, MITIGATION OF UNAVOIDABLE HAZARDS, LINES OF COMMUNICATION AND PARTICIPANTS, NOTIFICATION OF RAILROADS OR OTHER ENTITIES WITH CONTROL OF POSSIBLE HAZARDS, DEVELOPMENT OF OPERATING IN EMERGENCY PROCEDURES AND SAFETY BRIEFING FOR VEHICLE OPERATORS. NUMBER FOUR,
THE NATIONAL LEAGUE OF CITIES, NATIONAL ASSOCIATION OF COUNTIES, NATIONAL ASSOCIATION OF TOWNS AND TOWNSHIPS AND INTERNATIONAL CITY COUNTY MANAGEMENT ASSOCIATION -- ENCOURAGE MEMBERS TO REQUIRE AS PART OF THE PARADE AND SPECIAL EVENT APPROVAL PROCESS THAT ORGANIZATIONS CREATE A WRITTEN SAFETY PLAN AM A WHICH AT A MINIMUM ADDRESSES THE FOLLOWING ELEMENTS, RISK MITIGATION AND CONTINGENCY PLANNING WITH PROVISIONS FOR EVENT PARTICIPANTS AND OTHER STAKEHOLDERS, SAFETY BRIEFINGS, DRIVER AND VEHICLE SCREENING, SAY FLOAT OPERATION AND NOTIFICATION OF RAILROADS OR OTHER ENTITIES WITH CONTROL OVER POSSIBLE HAZARDS. FINALLY, RECOMMENDATION FIVE AND SIX, 60 AND A COMPANION RECOMMENDATION TO FIVE, RECOMMENDATION FIVE TO THE INTERNATIONAL CITY COUNTY ASSOCIATION WITH THE ASSISTANCE OF FESTIVAL ASSOCIATION, NATIONAL LEAGUE OF CITIES AND NATIONAL ASSOCIATION OF COUNTIES, DEVELOP AND ASSIMILATE -- DISSEMINATE A RESOURCE TO CREATE GUIDELINES OF STANDARD OPERATING PROCEDURE ORDINANCES FROM THE SAFE PLANNING AND OPERATION OF PARADES AND OTHER SPECIAL EVENTS. RECOMMENDATION SIX WOULD USE THE SAME LANGUAGE AND WOULD BE ISSUED TO THE INTERNATIONAL FESTIVALS AND EVENTS ASSOCIATION COME A NATIONAL LEAGUE OF CITY AND THE NATIONAL ASSOCIATION OF COUNTIES.