The culture of rot started at the top with Al "everything was fine when I was there" Leach, who was the TTC GM from 1988 to just before this happened and fobbed the blame onto David Gunn. The whole organization was coasting on a great reputation and winning safety awards year after year in the 1980s. Nobody really paid much attention to the infrastructure and assumed that the system was infallible. The operator was trained under that assumption. The confluence of misfortune compounded it, the reflection of the headlights making the operator think a signal was illuminated, the extreme heat contributing to a signal malfunction which stopped the train ahead - if not for these things, the problem with the trip arms may not have been detected. There was blame to go around all over the place - who should have been charged other than the operator?