Reviewing Safety Breaches: The Waterfall Train Crash Accident Case

The Waterfall train accident in 2003, resulting in seven deaths and 40 injuries, was caused by critical safety breaches within the CityRail system. The primary cause was the train driver's incapacitation due to a heart attack, leading to overspeeding on a curved rail. Key safety breaches included inadequate medical standards for drivers, a flawed deadman system design, and the absence of a reliable backup system, with the guard lacking sufficient emergency response training. The accident prompted significant changes, including the implementation of task-linked vigilance systems, automatic train protection (ATP), and emergency door release mechanisms. These changes aimed to enhance safety by detecting driver incapacitation, preventing overspeeding, and improving emergency evacuation procedures. The case underscores the importance of a robust safety culture, effective leadership, and diligent risk management in preventing workplace accidents. Desklib provides access to similar case studies and solved assignments for students.

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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

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.
Practice Change
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.
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
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Coury, B. G., Ellingstad, V. S., & Kolly, J. M. (2010). Transportation accident investigation: The
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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-
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