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.
Waterfall Train Accident New South Wales
In the past years, there have been many cases of train accidents and train crashes in Australia and in overseas that mainly occurred as a result of breaching the safety requirements and rules. The report takes into consideration the Waterfall train accident of New South Wales and discusses the number of reasons that contributed the train crash. The Waterfall rail accident occurred on January 31, 2003 near Waterfall in New South Wales Australia. The accident gained a considerable media coverage concerning its cause (Glendon & Evans, 2007). A number of causes of the accident was speculated, the major one out of them being the excessive speed of the train and poor maintenance (Donaldson, Edkins & Victoria, 2004). The report gives an overview of the Waterfall rail accident and its causes and analyses the process by which similar rail accidents can be prevented. The details of the Waterfall train accident are discussed in the following paragraphs.
On January 31, 2003, a four car Tangara passenger train derailed in about 2 kilometres south of the waterfall railway station. The details about this train accident were difficult to gather as the train driver died in the accident and was not available to provide any concrete information about the accident. The train guard failed to provide concrete evidence as well (McIntosh & Edkins, 2007). Apart from that, the possibility of a significant mechanical malfunctioning was not readily identifiable as well.
This was an accident associated with rail derailment. The derailment of a vehicle mainly occurs when the trains run off from its rails. There are a number of reasons behind the derailment of a train as it can be caused by collision with another object, error in the operation of a train, mechanical failure of the wheels and so on (Tichon, Wallis & Mildred, 2006). The reason behind this accident is needed to be identified for further analysis in this matter.
The accident fatally injured the train river and six passengers. It was estimated that the Tangara Train of G7 rolled over a speed of 117km/h on the left hand bend when the driver became incapacitated from a cardiac event (Priestley & Lee, 2008). When the driver suffered a cardiac arrest, the train was travelling at 117 km/hr and soon approached a curve in the tracks leading to the accident. Due to the lack of control in the curve, the train derailed and collided with the rocky walls thus leading to death of seven people including the driver and injured many.
This accident questions the safety requirements of the public vehicles and to what extent it is being followed. Following the incident an inquiry was set to identify the causes of this accident and the breach of which safety requirements led to the same. The accident was found to be critical due to the remote location of the accident site. The rescuers had to carry heavy lifting equipments for almost 1.5 km to reach the site (Ross, 2006). Generally it is seen that the Tangara trains make use of a number of safety measures and vigilance devices to address the problems that can arise if a driver becomes incapacitated. Therefore, it can be confirmed that there were issues with the safety management process that led to the accident (Donaldson, Edkins & Victoria, 2004). The damage as a result of this accident was huge that the G7 train services were completely scrapped in 2005. The causes of this accident are discussed in the following section.
The Causes of the Accident: The Safety Breaches
The initial investigation of the problem unveiled that the G7 line has been reportedly reported for the technical problems. However, the mechanical operation branch had always overlooked those technical faults assuming them to be normal. One of the significant causes behind the accident was faulty Deadman’s handle (Innes & Watson, 2004). It was discovered that the deadman’s break was not applied. The reason behind this was that the train guard was in a micro sleep just prior to the accident. In both the cases, the basic safety requirements were compromised.
Further inquiry about the accident revealed that there were certain flaws in the deadman’s pedal as it did not appear to be able to operate as it was supposed to do. Although the inefficiency of the deadman’s break was a major cause, there were other reasons behind the problem as well. There were a number of safety breaches associated with this train accident. The accident investigation suggests that there were some obvious problems with the track that was a result of poor maintenance. Appropriate maintenance is one of the basic needs for any rail authority which was breached in this accident. Along with the certain issues in the track, there were inadequate safety management process that led to the problem. Further probe into the causes of the accident reveals that there were some mechanical failure resulted from the prior mechanical problems (Walker, 2006). This is another safety breach associated with the accident as the mechanical problems in the train or the track if identified should not be left unattended. These problems caused a surge in the traction power of the train leading to the failure of the brakes, and failure of the motor power. There were some notable human errors as well that contribution to the accident (Cheeseman, Jones & Macdonald, 2005). Although the health of the train driver was not good, the issues accident could have been avoided if there were no faulty machineries. It was also reported that the rocks and ballasts were placed on the track that contributed to the derailment of the train. Keeping the railway track free from any sort of disruption is an essential safety requirement that is needed to be followed. In this case, it has been observed that the City Rail was ineffective in keeping the most necessary safety requirements in working condition.
However, any concrete cause of the accident could not be identified. This was mainly because the train driver died in the accident and was not available to provide the information about the accident. Coupled with that, the train guard having being asleep prior to the accident was not available as well to give evidence (O’Flanagan & Seeley, 2016). Apart from that the possibility of a system malfunctioning was although speculated, it was not readily identifiable. The information about the causes of the accident could only be fetched from the technical analysis of the accident (Crash Simulation of the Waterfall Train Disaster, 2018). It was an unfortunate incident that claimed the lives of 7 people and injured more than 40 people. The changes to the policies or the practises that resulted from the incident are identified in the following section.
Changes to Policies or Practise
There has been a significant and notable change to the policies after the accident. The train G7 did not re enter into service after the accident. The flaws in the tracks, systems and machineries were identified and special commission made sure to address the problems. Following the accident, special focus were given to the deadman’s brake associated with each train. However, the human errors or negligence is difficult to address. More strict ventures are needed to control the accidents that are a cause of human errors (Prasser, 2006). It is unfortunate for a train to derail following the ill health of the driver. However, the mishap could have been avoided of necessary precautions were taken and had all the safety needs were in place.
A detailed technical analysis of the accident was done to identify the causes of the accident. The final report by the Special Commission of Inquiry (SCOI) was released on 17th January 2005. The report made 177 recommendations that led to certain changes in the existing policies and practises. The main recommendations that were made are as follows-
1. Equipping the Rail management centre with transcriber system to identify the precise locations in a rail network.
2. Every train should have two independent methods for emergency escape by the passengers.
3. Every passenger train should be fitted with an internal emergency door
4. There should be an alarm if a passenger tries to operate and emergency door.
The above mentioned safety requirements were enforced to reduce the similar accidents as that of waterfall rail.
The report discusses the major train accident of waterfall train that took place in 2003, near New South Wales. There were a number of causes behind the accident that were identified in the report. The main cause of the accident is found to be the faulty deadman’s brake coupled with other severe causes. The multiple machineries’ fault along with the human errors added to the already existing problems. The remote location of the accident spot made it difficult to collect certain evidences of the accidents. However, a detailed technical report proved that the major cause of the accident being poor maintenance and obstruction in the railway tracks. The accident led to the changes in certain policies and the practises which are further discussed in the report.
Cheeseman, P., Jones, G., & Macdonald, K. (2005). A risk-based approach to training. In AusRAIL PLUS 2005, 22-24 November 2005, Sydney, NSW, Australia.
Crash Simulation of the Waterfall Train Disaster | Finite Element Analysis (FEA) – LEAP Australia & New Zealand. (2018). Retrieved from https://www.finiteelementanalysis.com.au/featured/crash-simulation-waterfall-train-disaster/
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., & Evans, B. (2007). Safety climate in Australian railways. People and rail systems: human Factors at the heart of the railway. Ashgate, Hampshire, UK, 409-417.
Innes, C., & Watson, G. (2004). Safety regulators in the transport industry: captured agents for change. Employment Relations Record, 4(2), 13.
McIntosh, A. S., & Edkins, G. (2007). The Waterfall Train Accident: The Critical Role of Human Factors. People and Rail Systems: Human Factors at the Heart of the Railway, 419.
O’Flanagan, B., & Seeley, G. (2016). The Right Way, the Wrong Way, and the Railway. Human Factors and Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World, 193.
Prasser, S. (2006). Royal Commissions in Australia: When should governments appoint them?. Australian Journal of Public Administration, 65(3), 28-47.
Priestley, K., & Lee, G. (2008, March). Human factors in railway operations. In Railway Engineering-Challenges for Railway Transportation in Information Age, 2008. ICRE 2008. International Conference on (pp. 1-5). IET.
Ross, A. (2006). How Safe Is Safe Enough?. In Rail Achieving Growth: Conference Proceedings (p. 351). RTSA.
Tichon, J., Wallis, G., & Mildred, T. (2006). Virtual training environments to improve train driver’s crisis decision making. Proceedings of SimTecT, Melbourne, Australia, May.
Walker, C. (2006). Regulatory Reform in the Australian Rail Sector and the New Interorganisational Complexity. The Challenge of Balancing Economic Interests and Safety in a Complex Regulatory Environment. University of Bath, September, 7.