Waterfall Train Crash Accident Safety Breach Critical Review

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Waterfall Train Crash Accident Safety
Breach Critical Review
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.
Cause of the Accident
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.

Safety Breaches
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