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Cause of the Accident

1 Appraise the values, assumptions and models that underpin the development of risk assessment principles and of safety management processes
2 Identify and implement the principles of applied safety management premised on risk assessment and management
3 Critically analyse the systems approach to safety management responsibilities
4 Define and implement an integrated approach to safety systems
5 Discern the significance of safety culture to safety management
6 Advise on the integration of occupational health and safety programs into routine management systems
7 Produce and perform a risk assessment that identifies and apply the expected control measures

Rationale

Students of Safety and Risk Management need to understand and be able to apply safety management principles.A major part of the application of safety and risk management principles is the skill to analyse and evaluate safety incidents and to identify weaknesses and failures that led to safety breaches or major incidents. The analysis of Case Studies will develop students’ skills in risk management and practical application of theory.


Task


There have been many train crashes in Australia and overseas as a result of safety breaches. Choose one train incident that has occurred as a result of safety breaches and, with supporting evidence, discuss how safety breaches contributed to the train crash. In some cases, multiple breaches have led to the incident. Choose the safety breaches you feel contributed most heavily to the incident that you have chosen to discuss. Detail any changes to policy or practice that resulted from the incident and how this was implemented. Use evidence from existing literature to support the discussion.

Criteria

Your assignment will be assessed on the following:


– Depth of discussion of the safety breaches which lead to the incident
– Depth of discussion of the changes to policy or practice that resulted from the incident.
– Use of evidence to support the discussion using the APA referencing system.

Case Study 2 Rationale

Safety and Risk Management are critical aspects of a workplace, and breaches are punishable under Work Health and Safety Law. This task encourages students to analyse and conceptualise responses to safety breaches in a given situation and make decisions based on the evidence provided.

Read the online article from the following resource:

In an essay describe the workplace, the hazards and how this safety breach could have been avoided. What ac- tually happened and how did SAFEWORK resolve this issue? What could have been done differently to prevent his incident from occurring. How would you address this issue if you were responsible for the safety systems in this workplace? Be sure to include evidence from scholarly resources to support your discussion

Cause of the Accident

Introduction

Australia has experienced many train crashes over the past years as a result of safety breaches. The crash incidences have caused deaths and destruction of properties. Safety breach refers to failure to apply safety measures and risk management principles that lead to adverse outcomes in a workplace such as job accidents, medical illness, injuries and deaths (Mylett, 2010). One of the tragic train incidents in Australia as a result of safety breach is the Waterfall Train Accident that happened on 31st January 2003. The accident led to loss of seven lives and 40 injuries. The critical review aims to identify safety breaches that led to the incident and changes to policy or practice that resulted from the incident. This will involve reviewing relevant literature and Waterfall Train Accident incident as evident to support in depth discussion on this paper.

The Waterfall train accident occurred approximately 0714 hours on 31st January 2003 when a State Rail Authority (SRA) passenger train overturned and collided with rockcutting and stanchions at high speed (Donaldson, Edkins & Victoria, 2004). The train was scheduled from Sydney to Port Kembla and ended up crashing 2km south of Waterfall (McInerney, 2004). The train had 47 passengers and 2 crews on board. The incident led to the driver’s death together with six passengers and the Tangara train known as G7 getting extensively damaged. The incident was caused by driver’s incapacitation to control the train after suffering a heart attack. The train was at a speed of 117km/h in a curved rail that was marked a maximum speed of 60km/h (McInerney, 2005). This led to the train derailing, colliding with the rock wall and overturning. According to investigations, the driver became incapacitated to control the train due to a pre-existing medical condition (Donaldson, Edkins & Victoria, 2004). The driver’s loss of control led to continued acceleration with maximum power applied. The train risk controls were deadman system and a guard and both failed to intervene and take control after the driver’s incapacitation. The driver’s pre-existing health condition and failure of risk controls systems therefore caused the Waterfall Train Crash.

Several safety breaches caused the Waterfall Tangara Train Crash. The safety breaches caused the train to exceed the maximum speed for a curve rail leading to derailing and crash. There were safety beach in terms of safety culture, safety leadership and principles of hazard identification in maintaining medical standards, lack of a risk backup system, training of manpower and ineffective deadman system. The medical standards of the driver had not been updated effectively over time. The medical practitioners’ applying tests in the organization were not aware of most significant matters to work tasks that were being undertaken (Wilson, 2007). This means that they failed to foresee catastrophic consequences that would happen as a result of sudden collapse of a driver in an electric train. They had believed that the deadman system was effective to control risks of driver’s sudden collapse. This undermined the safety culture and risk management activities to minimize undesirable outcomes (Borys, 2009). The second safety breach was deadman system design functionality failure. The deadman system installed in the train failed to detect that the driver had collapsed because of the device fundamental design issues. The organization deadman system was designed to be held suppressed by a master controller handle or by pedal held depressed by leg force. The investigations found that people with heavy body had capacity to hold the pedal to it suppressed position with their dead weight. This means that a heavy person did not require conscious efforts to suppress the deadman pedal hence the system could not be activated in a situation where the driver has a heavy body (Kenny, 2015). According to investigations, the deadman design deficiencies had been identified 15years prior to the occurrence of the incident but the organization management had not acted on the warning. This shows that the management had breached safety leadership by not acting on the design that was deemed to fail detecting incapacitation in certain cases (Leveson, 2015). The third risk control failure as a result of safety breach is lack of a back up. The guard crew was the only available backup that could have saved the train from the accident. The train had a guard who was supposed to detect the train an authorized speed and apply brakes. This was not the case as the guard was found to be unobservant and indecisive at the time of the incident. This means that the guard had deficient training on detecting and handling an emergency.  This shows that the organization had breached the safety culture of equipping employees with emergency response skills (Pidgeon, Turner, Blockley, & Toft, 2018). The organization also had insufficient assessment of the existing control measures to backup the existing system. The train lacked another hardware device fitted to detect driver’s incapacitation apart from deadman pedal. In particular, there was not vigilance control devices fitt3ed in the train.

Safety Breaches

The Waterfall Accident had implications to train safety and risk management practices. Several practices have been adopted by all CityRain trains, RailCorp and to Sydney Trains and NSW TrainLink. The CityRail trains added an additional safety feature. Before the accident, the trains only had deadman pedals or handles that lacked backup in case of their failure. To resolve this safety issue, all CityRail trains have since been fitted with an additional safety feature that is task-linked vigilance. The task-linked vigilance system resets a timer when a driver activates train’s certain controls and if the system detects no control change, an alarm is activated that includes a buzzer sound and flashing lamp that the driver needed to acknowledge (Glendon, Clarke & McKenna, 2016). In case the driver fails to acknowledge the vigilance button, the vigilance system gets automatically activated and emergency brakes are applied. The vigilance system also has data loggers that record the crews’ actions while working and train’s speed. The vigilance system therefore enhances the effectiveness of detecting driver’s incapacitation in addition to existing deadman system. The second practice that changed after the Waterfall accident is modification of the emergency exit door. During the accident, the rescue workers had a hard time in the scene trying to rescue trapped passengers because they did not have the emergency door keys. This emergency door mechanism was changed to allow opening of the emergency door without keys. After the accident, the RailCorp adopted this change and has over the years installed emergency exit release mechanism to all newly manufactured/assembled trains. The RailCorp and CityRail have also incorporated the emergency door release mechanism to allow passengers to open the door from inside in case there is an accident and the train crew are incapacitated. The emergency door change practices aimed to make it easy to evacuate trapped passengers and rescue them in case of an accident. This safety measure therefore ensure there is no repeat to what happened in Waterfall train accident where the rescue workers took hours to open the emergency doors and facilitate evaluation and treatment of injuries. Another practice that has been implemented after the Waterfall accident is the Automatic Train Protection (ATP). The ATP is a protection system fitted on a train that continually monitors train’s speed to ensure it compatible or within the permitted speed limit by signalling (Coury, Ellingstad, & Kolly, 2010). In case the train is above the permitted speed, the ATP system automatically gets activated and applies emergency brakes that stop the train. The ATP system was first implemented by the RailCorp on Blue Mountains Line and then to other Rail lines across NSW TrainLinks and Sydney Trains. The ATP system is therefore crucial to preventing possible accidents by applying emergency brakes where the driver exceed speed limits.

Case Study 1

Conclusion

The Waterfall train accident in 2003 was as a result of safety breaches. The train operator CityRail lacked a safety culture, safety leadership and undermined principles of risk management. The cause of the accident was driver’s incapacitation to control the train leading to over speeding in a curved rail. The driver became incapacitated as a result of heart attack collapsing few kilometres after departing Waterfall Station. The safety breaches were poor medical standards by the organization medical practitioners, ineffective deadman design system, and lack of a backup system. The guard was the only backup but lacked emergency skills. The train accident cause 7 deaths and 40 injuries and it occurrence led to several practices changes. These practice changes include a task-linked vigilance system, an automated train protection (ATP) system, and emergency door release mechanism. Therefore, it can be concluded that organizations require a safety culture, safety leadership and application of risk management principles to prevent, reduce and avoid workplace risks. 

References

Borys, D. (2009). Exploring risk-awareness as a cultural approach to safety: Exposing the gap between work as imagined and work as actually performed. Safety Science Monitor, 13(2), 1-11.

Coury, B. G., Ellingstad, V. S., & Kolly, J. M. (2010). Transportation accident investigation: The development of human factors research and practice. Reviews of human factors and ergonomics, 6(1), 1-33.

Donaldson, K., Edkins, G., & Victoria, D. O. I. (2004, October). A case study of systemic failure in rail safety: The Waterfall accident. In International Rail Safety Conference, Perth.

Glendon, A. I., Clarke, S., & McKenna, E. (2016). Human safety and risk management. Crc Press.

Kenny, K. E. (2015). Blaming deadmen: Causes, culprits, and chaos in accounting for technological accidents. Science, Technology, & Human Values, 40(4), 539-563.

Leveson, N. (2015). A systems approach to risk management through leading safety indicators. Reliability Engineering & System Safety, 136, 17-34.

McInerney, P. A. (2004). Interim Report of the Special Commission of Inquiry into the Waterfall Rail Accident.

McInerney, P. A. (2005). Special Commission of Inquiry into the Waterfall Rail Accident. Final Report, Vol. 1. NSW Government, Sydney.

Mylett, T. (2010). Safety culture: conceptual considerations and research method. International Journal of Employment Studies, 18(1), 1.

Pidgeon, N. F., Turner, B. A., Blockley, D. I., & Toft, B. (2018). Corporate safety culture: improving the management contribution to system reliability. In Reliability 91 (pp. 682-690). Chapman and Hall/CRC.

Wilson, J. R. (Ed.). (2007). People and rail systems: human factors at the heart of the railway. Ashgate Publishing, Ltd..

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