Safety Breaches that led to the Waterfall Railway Accident

This paper provides details of the investigation report by the Ministry of Transport (MOT) regarding the Waterfall accident. The investigation found out that there were higher chances that the driver was incapacitated from the controls due to the early medical condition a few minutes before leaving Waterfall station. The paper discusses the investigation into the accident, the causes of the accident, changes to policy or practice that resulted in the incident, and the lessons learned from the accident.

Running head: WATERFALL RAILWAY ACCIDENT 1
Safety Breaches that led to the Waterfall Railway Accident
Student’s Name
Institutional Affiliation

WATERFALL RAILWAY ACCIDENT 2
Safety Breaches that led to the Waterfall Railway Accident
Introduction
There have been cases of rail accidents all over the world, and most of the accidents have
always been found to have been caused by various safety breaches. However, so many other
disasters have equally been reported to have occurred without necessary having specific breaches
of the safety regulations by the operators of the trains (Donaldson, Edkins, & Victoria, 2004).
Numerous safety precautions that have been put in place are intended to ensure that cases of such
accidents are reduced to an attainable level (Bahr, 2014). In Australia for instance, the body in
charge with managing the safety-related issues of trains have always ensured that such measures
are updated after every accident to ensure that there is no loophole (Donaldson, Edkins, &
Victoria, 2004). Australia has witnessed tragic accidents some of which include the incident
where a truck collided with a V/Line train that took place in 2007 claiming 11 lives including
children and leaving several others injured ("Families 'still hurting' 10 years on from Kerang rail
disaster", 2017). However, the findings demonstrated that there were no safety breaches by the
operators of the truck or the train (Glendon & Evans, 2007). Before the V/Line accident, there
was also the case of Waterfall railway incident that occurred in 2003, and seven people lost their
lives. This paper provides details of the investigation report by the Ministry of Transport (MOT)
regarding the Waterfall accident.
The investigation into the Waterfall Accident
It was on 31 January 2003 when Suburban passenger train left Sydney for Port Kembla
went out of the track before overturning while moving at high speed when was taking a curve
that is next to the Waterfall railway station. This was one of the most tragic rail accidents to have
ever happened as six people, and the train driver lost their lives while several others were left

WATERFALL RAILWAY ACCIDENT 3
with injuries. Due to its severity, there was great concern from the investigative agencies to find
out what could have resulted in such a tragic accident (Carey, 2017). Therefore, Honourable
Peter Mclnerney QC conducted an inquiry into the matter between 2003 and 2004 to find out
possible causes of the accident and come up with proper measures to prevent similar
occurrences. On the other hand, there was the investigation by MOT under the Rail Safety 2002,
and it was done as per the Australian Standards AS 5022-200. The two investigations were all
done to uncover the circumstances that led to the accident and provide appropriate measures to
prevent future occurrences.
The investigation by MOT was meant to examine rolling stock, human factors, and
infrastructure (Priestley & Lee, 2008). The outcome of the two investigations found out that
there were higher chances that the driver was incapacitated from the controls due to the early
medical condition a few minutes before leaving Waterfall station (Burton & Egan, 2010). It was
stated in the findings that the deadman system, as well as the guard, were selected risk controls
against the incapacitation of the driver.
The first cause of the accident can be stated to be the high speed of the train that was
above the speed for the curve. However, it is possible to identify systematic failures of the risk
controls that starts from the medical standards, training and the deadman system (Authority,
2016). The train is expected to reduce its speed if the driver is incapacitated. In the case of the
Waterfall accident, deadman system did not lower to the required level of risk (Mcintosh, 2007).
It was equally noted that several warnings concerning the flaw were not attended to in the
operational history of Tangara. This made it impossible for the deadman system to detect that the
driver was incapacitated to slow down.

WATERFALL RAILWAY ACCIDENT 4
The interim report by the Special Commission of Inquiry (SCOI) and the MOT had
revealed some issues already such as the state of the driver, the problem with the deadman
system, and multiple others. For instance, the maintenance history of the G7 was identified
considered essential to be able to find out whether any defect could have led to the accident. The
investigation found that there were several deficiencies regarding the train maintenance. For
instance, the drivers did not perform their required maintenance, which involves checking on the
state of the train by going through the basic checklist (Elms, 2001). It is from such failures that
it was impossible to understand the imminent danger that the train.
The fact that the G7 that was fitted was not working at the time of the investigation made
it nearly impossible to be able to arrive at the most critical facts (Punzet, Pignata, & Rose, 2018).
For instance, there was a need to find facts about the train driver, Mr Zeides, was found not to
have operated the controls of the train shortly after he left Waterfall railway station. The data
would have been useful in determining the possible defects on the way the G7 was being
operated between the time of its derailment and the time it left Waterfall Station (Mcintosh,
2007). It would have helped know whether Mr Zeides applied the brakes or whether the braking
systems were in good condition. However, it took several engineering hours to be able to get
such information and the resources wasted due to the failure of the implementation of such
requirements was significant.
It is even more worrying to note that the G7 was fitted adequately with a data logger, but
it was not being used. The data logger was found to be functional when testing was to be done in
the early January 2003, yet it was not in use at the time it got an accident. The violation went
against the agreement that was entered into by the SRA the relevant trade union (McIntosh,
2017). The rescheduling was done for the testing to be done in mid-January, but it still did not

WATERFALL RAILWAY ACCIDENT 5
take place due to lack of rostering arrangement for staff that would allow for the testing. As such,
G7 did not turn on its data logger as at the time it got involved in the accident on 31 January
2003 (Mcintosh, 2007). This is a clear demonstration of poor project management as well as
inadequate industrial relations by the SRA.
The fact that the driver could be allowed to operate the train even though she was not in
his health best was a clear demonstration of the limited guideline on the best way to determine
medical fitness (McInerney, 2005). The management failed to establish the best guidance on the
health standards that would ensure that only those in their right health condition are allowed to
report for work.
Changes to Policy or Practice that Resulted in the Incident
The factors that led to the accident at Waterfall Station demonstrate that there was a
significant deviation from the medical standards required for the train crews. The Rail Safety
Regulators are expected to have medical standards for the rail industry that guide how the train
crews and other workers follow when at work (Michel & Gardiner, 2014). The failure to come
up with such a standard resulted in the team taking over the train while is in poor health.
The safety culture seemed to have changed significantly from the top management. The
management did not approach safety issues with the seriousness deserved (Hocking, 2006). For
instance, it was found that reporting safety issue would quickly result in the punishment of the
one raising the safety concern (McInerney, 2005). That is contrary to what is expected of such a
reputable institution. It is always assumed that those who bring safety issues should be rewarded
and not punished. The organization focused more on time running at the expense of the safety of
the passenger and workers (Donaldson, Edkins, & Victoria, 2004). Promoting on-time running

WATERFALL RAILWAY ACCIDENT 6
by compromising on the safety measures exposes the company to inefficiency challenges that are
more likely to impact greatly on the very on-time running.
Consequently, there is a need to emphasise on the on-time running while at the same time
having safety considerations as a secondary. The practice of performing regular maintenance
seems to have changed significantly. The organisation did not perform repair and maintenance
regularly to ensure that the train is in excellent condition. It is for this reason that it was not able
to understand the state of the deadman system.
Conclusion
The train accidents witnessed all over the world and more particularly in Australia has
always been due to some element of failure in complying with the send standards. The waterfall
accident is one of the similar cases that demonstrate several instances where safety breaches
contribute to the train accidents. Some of the human factor lessons that can be learned for the
accident is the failure by the management to adhere to the medical examination standards that
promote the safety of workers. It was a gross mistake for a crew who is not in his health best to
be on duty leading to such a fatal accident. There was no proper training during the initial and
recurrent training programs that led to the failure in testing the condition of the G7 data logger to
find out whether the deadman system was in its best condition. The accident was promoted by
several safety breaches that must not be allowed in the railway industry in the coming future.

WATERFALL RAILWAY ACCIDENT 7
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