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A tragedy of the scope and magnitude of the Waverly Train Disaster is rarely, if ever, the result of a single error, suspended in time. It is nearly always the consequence of a sequence of errors, both immediate and long in the making. In this way it is not unlike the heart attack that follows from years of atherosclerosis, the chronic hardening of the arteries which, combined with multiple lapses in judgment that build up over time, leads finally to the sudden, cataclysmic event.
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Yasmine S. Ali, MD (Walk Through Fire: The Train Disaster that Changed America)