Safety and Risk Management

This report analyzes a case of a railway accident caused by safety breaches and technological faults. It discusses the casualties, the incident, investigation, lessons learned, and major changes made after the incident.

Running Head: SAFETY AND RISK MANAGEMENT
SAFETY AND RISK MANAGEMENT
Name of the Student
Name of the University
Author Note

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Executive Summary
The aim of this report is to analyze a case of railway accident occurred in the past due safety
breaches of the government. It will discuss in detail about the casualties and technological
fault due to which the incident occurred. On the other hand, it will provide a detailed
demonstration about the changes in policies and strategies that led to such an accident.

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Table of Contents
Introduction................................................................................................................................3
Incident...................................................................................................................................3
Investigation and Result.........................................................................................................5
Lessons Learned from the Incident........................................................................................6
Major Changes after the incident...........................................................................................6
Conclusion..............................................................................................................................7
References..............................................................................................................................8

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Introduction
Railway system is an integrated system of transportation network, which helps to
carry goods and people from one place to other. Railway being one of the oldest technology
of transportation still is the most cost effective medium of transportation. The technology of
railway has evolved overtime. First, the steam engine was introduced in the market. Later, it
has transformed into diesel and electricity making the system both convenient and cost
effective.
However, the life has become easier with the increase in the frequency of usage of
this mode of transportation. Through this glorious journey of evolution of the global
transportation system, a numerous number of people have given their life due to minimal
mistakes (Bradt, Bartley, Hibble & Varshney, 2015). On the other hand, railway accidents
have contributed to huge economic losses due to loss of goods in the way of transporting
them from one place to another. This paper will take a railway accident from the pages of
history and provide a descriptive report on the incident. The undertaken incident is Granville
Train Disaster.
Incident
Granville Train Disaster occurred in 18th of January in the year 1977. The location of
the accident was at Granville in New South Wales, Australia. This incident is recorded as one
of the worst train accident in the history of the world and the deadliest in Australia till date
(Hong, Wang, Su & Cheng, 2014). The accident happened when a fully loaded passenger
train missed tracks of the railway and crashed into the support boundary of the road bridge.
Moreover, after the train hit the support of the road bridge, it collapsed on top of the train
killing 83 people and injuring 213 other passengers. The number of people affected due to the
incident were approximately about 1300.

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The train was a 46 class electric locomotive 4620 prototype. The train departed from Mt.
Victoria located between the Blue Mountains in New South Wales and the destination of the
train was the city of Sydney at 6:10 am. The incident occurred at 8:10 am when it was about
to enter the Granville Station when the train missed its tracks and collided with the bridge
support which was made out of steel and concrete (Leigh, 2015). The bridge was located in
Bold Street. The huge force of the train broke the concrete pillars and the locomotive and the
first two carriages passed the barricades. After the three carriages and the engine collided
heavily, the first carriage broke free and crashed for the second time, this time sideways with
the sidelines and railway boundaries and opened up from the middle into two halves. Due to
this, eight passengers in the train immediately were killed. The second carriage escaped the
massive collision and moved forward away from the bridge (Kayes & Yoon, 2016). The main
accident took place when the second part of the third carriage and the first part of the fourth
carriage came under the weakened bridge. Then the main disaster took place when the bridge
collapsed on the above-mentioned portions of the train with a number of cars on the bridge.
The weight of the bridge was 570 tons and completely fell upon the train crushing the
carriages and killing all the passengers inside (Ling, 2014). Half of the total number of
passengers in the fourth and the third carriage were immediately killed due to the heavy
damage caused by the demolition of the over bridge. The other passengers inside the third
and the fourth carriage remained trapped inside for hours with fatal injuries. They injured
passengers broke their limbs, spine and torso under the weight of the bridge. The passengers
who were still alive after they were crushed died as soon as the weight of demolished parts of
the bridge were removed by the rescuers due to crush syndrome (Samouei, Abedi & Ferdosi,
2014). The rescuers faced great difficulties as they were trying to remove the heavy parts of
the bridge and the train away from the surviving passengers as the other parts of the bridge
started falling over the area. This decreased the time span; the rescuers were getting to rescue

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the passengers. As a result, two rescuers got trapped and the portable generator in the train
was crushed within seconds due to heavy vertical pressure. The second part of the disaster
occurred when the Liquid Petroleum Gas cylinders in the train that were kept as reserves for
heating the carriages in winter were cracked open under the heavy pressure (Ingham &
Redshaw, 2017). The leaked gas entered into the respiratory system of the injured passengers
who were trapped inside the demolished carriage. Due to the leakage of this highly
combustible gas, the power rescue tools, which included gas cutters and welding equipment,
could not be used to fasten the process of rescuing the trapped passengers. So the New South
Wales Fire Brigade stepped in and started insulating the process by spraying jets of water to
reduce the probability of ignition (Rapattoni, Dauth, Muscat & Prasad, 2017). The total
process of rescuing passengers started on 8:12 am on Tuesday and ended on 6:00 am on
Thursday. In total 84 units of people were killed in the incident which included a child which
was still in the womb of the mother.
Investigation and Result
The investigation process started soon after the rescuing mission ended and the area
was cleared of all possible hazards. The primary reason, which caused the massive accident,
was due to the poor condition of the permanent way. Due to the inferiority of the structure
and the quality of the tracks, which were not changed for a long period expanded due to the
dissipation of heat which caused the train’s front left wheel to lose track and crush into the
over bridge support pillars (Chattopadhyay, Raman & Alam, 2014). When researched further,
after almost 30 years later it was found out that the main reason behind the accident was due
to the absence of maintenance of the locomotive, which belonged to Class 46. Due to the lack
of maintenance, the wheel on which the locomotive stood i.e. the L6 wheel was faulty and
was in a bad condition. Due to the lack of replacement, the L6 wheel was allowed to be used

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and the decision became a disaster. The railway board did not have a spare wheel for the L6,
which could have been used as an alternative to the damaged one (McFarlane & Van Hooff,
2014). The route of the train was also an important way of commuting as it connected the two
cities so could not be suspended. The replacement and back up was available but was sold in
a scrap auction to raise funds for the Public Transport Commission of Australia. Later it was
found out that the two events were not the only reason behind the accident. It was later found
that the structure of the over bridge itself was faulty in design (Bbc.com, 2019). The deck
base, which was made of iron, was one meter below the concrete bitumen road. The carriage
structure were built with wood so the additional weight of the bridge fell directly on the
wooden structure and demolished the roof of the carriage.
Lessons Learned from the Incident
The main lesson learned from the incident that the absence of emergency rescue team
near such an accident-prone zone resulted in inclusion of volunteers. The volunteers rather
than actually helping complicated the whole process (Ranse & Fcena, 2017). They rather
were keen to watch the whole incident closely rather than actually helping the victims. The
railway system also did not have any psychological team employed to the emergency workers
for mental support. Due to the absence for the psychological team, the rescuers fell in a
trauma for over a month. Later, in the year 1977, the National Association of Loss and Greif
was established in response to the disaster to look after any natural and other kind of
disasters. Moreover, a locomotive and a coal wagon struck twice before the rail bridge at the
Bold Street in the year 1967 and 1975 respectively.
Major Changes after the incident
The defects that caused the major accident must have been identified and repaired by the
railway authorities. The main body held responsible for the accident was the Public Transport
Commission. The Australian Railway Budget constraint contributed largely to the incident.

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As a reaction to the incident, the government employees were trained in disaster management
and crisis intervention. The newly elected Wran Government revised the railway budget and
an additional budget of $200 million was allotted to the railway improvement plan.
\
Conclusion
Today the world remembers the incident as one of the worst disasters in Global
history. The ‘Memorial Trust’ an unrecognized group of volunteers collected funds and built
a memorial in the memory of the passengers who died in the incident.

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References
Bbc.com. (2019). The rail disaster that changed Australia. Retrieved 4 September 2019, from
https://www.bbc.com/news/world-australia-38645976
Bradt, D. A., Bartley, B., Hibble, B. A., & Varshney, K. (2015). Australasian disasters of
national significance: An epidemiological analysis, 1900–2012. Emergency Medicine
Australasia, 27(2), 132-138.
Chattopadhyay, G., Raman, D., & Alam, M. R. (2014). A Study of Derailment in Australia:
Analysing Risk Gaps with Remote Data Monitoring. In Engineering Asset
Management 2011 (pp. 21-31). Springer, London.
Hong, M., Wang, Q., Su, Z., & Cheng, L. (2014). In situ health monitoring for bogie systems
of CRH380 train on Beijing–Shanghai high-speed railway. Mechanical Systems and
Signal Processing, 45(2), 378-395.
Ingham, V., & Redshaw, S. (2017). Connecting community organisations for disaster
preparedness. International journal of safety and security engineering, 7(1), 52-64.
Kayes, D. C., & Yoon, J. (2016). The breakdown and rebuilding of learning during
organizational crisis, disaster, and failure. Organizational Dynamics, 45(2), 71-79.
Leigh, A. (2015). The Luck of Politics: True Tales of Disaster and Outrageous Fortune.
Black Inc..

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Ling, J. B. (2014). Coping with acute workplace disasters. Coping, Health and
Organizations, 71.
McFarlane, A. C., & Van Hooff, M. (2014). Learning for the future: The challenge of disaster
research. Australian & New Zealand Journal of Psychiatry, 48(7), 600-602.
Ranse, J., & Fcena, R. F. (2017). Australian Civilian Hospital Nurses’ Lived Experience of
the Out-of-hospital Environment Following a Disaster (Doctoral dissertation, Flinders
University, School of Nursing & Midwifery.).
Rapattoni, F., Dauth, J., Muscat, J., & Prasad, P. (2017, April). AS (NZS) 5100-2017:
derailed train collisions. Leading safety provisions in bridge design to prevent
disasters. In Austroads Bridge Conference, 10th, 2017, Melbourne, Victoria,
Australia.
Samouei, R., Abedi, M. R., & Ferdosi, M. (2014). The absence of positive psychology in
disasters. International Journal of Health System and Disaster Management, 2(4),
241.