The Waterfall rail accident was a train accident that occurred on 31 January 2003 near
Waterfall, New South Wales
Waterfall is a small suburb in southern Sydney, in the state of New South Wales, Australia. It is 40 kilometres south of the Sydney central business district in the Sutherland Shire. It is the southernmost suburb of Sydney in the eastern cor ...
, Australia. The train
derailed, killing seven people aboard, including the train driver.
The accident is famously remembered by
systems engineers due to the poorly designed safety systems.
Incident
On the day of the disaster, a
Tangara interurban train service, set G7, which had come from Sydney
Central station
Central stations or central railway stations emerged in the second half of the nineteenth century as railway stations that had initially been built on the edge of city centres were enveloped by urban expansion and became an integral part of the ...
at 6:24 am, departed Sydney
Waterfall railway station moving south towards
Port Kembla station via
Wollongong
Wollongong ( ), colloquially referred to as The Gong, is a city located in the Illawarra region of New South Wales, Australia. The name is believed to originate from the Dharawal language, meaning either 'five islands/clouds', 'ground near wate ...
. At approximately 7:15 am, the driver suffered a sudden heart attack and lost control of the train. The train was thus travelling at as it approached a curve in the tracks through a small cutting. The curve is rated for speeds no greater than . The train derailed, overturned and collided with the rocky walls of the cutting in a remote area south of the station. It was reported that the rescuers had to carry heavy lifting equipment for more than to reach the site. Two of the carriages landed on their sides and another two were severely damaged in the accident. In addition to the seven fatalities, many more passengers were injured.
The subsequent official inquiry discovered the
deadman's brake had not been applied. The train
guard
Guard or guards may refer to:
Professional occupations
* Bodyguard, who protects an individual from personal assault
* Crossing guard, who stops traffic so pedestrians can cross the street
* Lifeguard, who rescues people from drowning
* Prison ...
's solicitor stated that the guard was in a
microsleep
A microsleep is a sudden temporary episode of sleep or drowsiness which may last for a few seconds where an individual fails to respond to some arbitrary sensory input and becomes unconscious.International Classification of Sleep Disorders, , pa ...
for as much as 30 seconds, just prior to the accident.
The experienced human-factors accident investigator determined the organisational culture had the driver firmly in charge, making it psychologically more difficult for the guard to act.
Causes of the accident
Tangara trains have a number of safety and vigilance devices installed, such as a
deadman's brake, to address problems when the driver becomes incapacitated. If the driver releases pressure from this brake, the train will safely come to a halt.
The train in question was a four-car
Outer Suburban Tangara set, numbered G7 and fitted with a
Mitsubishi Electric
, established on 15 January 1921, is a Japanese multinational electronics and electrical equipment manufacturing company headquartered in Tokyo, Japan. It is one of the core companies of Mitsubishi. The products from MELCO include elevators an ...
alternating current
Alternating current (AC) is an electric current which periodically reverses direction and changes its magnitude continuously with time in contrast to direct current (DC) which flows only in one direction. Alternating current is the form in whic ...
traction system for evaluation purposes. The driver was in the leading driving carriage and the guard was in the rear driving carriage, in between which were two non-driving motor cars. On this service, the guard, who could have applied the emergency brake, and the deadman's brake were the main safety mechanisms in place.
The train was later found to be travelling in excess of as it approached the curve where the accident occurred. Neither the deadman's brake nor the guard had intervened in this situation, and this excessive speed was found to be the direct cause of the accident. Training of train staff was also found to be a contributing factor in the accident.
Train G7 did not re-enter service. It was scrapped in 2005 due to the damage sustained in the accident as all four cars were damaged beyond repair.
These were the official findings of the
NSW Ministry of Transport investigation of the accident. A report of the accident, managed by Commissioner
Peter McInerney
Peter Aloysius McInerney , (1927-2014) was an Australian barrister and New South Wales Supreme Court judge.
Biography
McInerney was born in Goulburn, New South Wales, the only child of grazier Leslie McInerney and his wife, Florence (née Smith ...
, was released in January 2004.
Systemic causes and ignored technical problems
It was reported that G7 was said to have been reported for technical problems "possibly half a dozen times" and had developed a reputation amongst the mechanical operations branch, saying the problems were "normal" for the set in question. During the six months leading up to the accident, three reports of technical problems were made.
The inquiry found a number of flaws in the deadman's handle (which was not implicated in the accident) and related to the deadman's pedal:
* The dead weight of the unconscious and overweight driver appeared to be enough to defeat the deadman's pedal, of which 44%
[ of Sydney train drivers' legs were of sufficient mass.][
* The design of the deadman's pedal did not appear to be able to operate as intended with drivers above a certain weight.][
* Marks near the deadman's pedal indicated some drivers were wedging a conveniently-sized red signalling flag to defeat the deadman's pedal to prevent their legs from ]cramp
A cramp is a sudden, involuntary, painful skeletal muscle contraction or overshortening associated with electrical activity; while generally temporary and non-damaging, they can cause significant pain and a paralysis-like immobility of the aff ...
ing in the poorly-configured footwell and to give themselves freedom of movement in the cabin.[
Some of the technical problems reported for Tangaras generally, included brake failure and reported power surge problems. After the accident, they were often blamed by some for being the cause of the accident. Many of the survivors of the accident mentioned a large acceleration before the accident occurred. Furthermore, there was an understanding that the emergency brake should be seldom used because the train would accelerate between before the brake came into effect. It was noted that the G7 trainset was the only train in the Tangara fleet to use 3-phase induction motors, and that these are not able to "run-away". Furthermore, the majority of braking and traction system components were thoroughly examined and tested by experts from Australia and overseas, and found to be working normally. Those damaged in the crash were examined and were also found not to have had pre-existing damage able to cause such an accident.
Official findings into the accident also blamed an "underdeveloped ]safety culture
Safety culture is the collection of the beliefs, perceptions and values that employees share in relation to risks within an organization, such as a workplace or community. Safety culture is a part of organizational culture, and has been describe ...
". There has been criticism of the way CityRail managed safety issues, resulting in what the NSW Ministry of Transport termed "a reactive approach to risk management".
At the inquiry, Paul Webb, Queen's Counsel
In the United Kingdom and in some Commonwealth of Nations, Commonwealth countries, a King's Counsel (Post-nominal letters, post-nominal initials KC) during the reign of a king, or Queen's Counsel (post-nominal initials QC) during the reign of ...
, representing the guard on the train, said the guard was in a microsleep
A microsleep is a sudden temporary episode of sleep or drowsiness which may last for a few seconds where an individual fails to respond to some arbitrary sensory input and becomes unconscious.International Classification of Sleep Disorders, , pa ...
at the time of the question, for as much as 30 seconds, which would have removed the opportunity for the guard to halt the train. Webb had also proposed there had been attitudes that the driver was completely in charge of the train, and speeding was not an acceptable reason for the guard to slow or halt the train, which would have been a contributing factor in the accident.
Prior to this derailment, neither training nor procedures mandated the guard to exercise control over the speed of the train by using the emergency brake pipe cock ("the tail"). Apart from the driver being considered to be the sole operator of the train, the emergency brake pipe cock does not provide the same degree of control over the automatic brake as a proper brake valve. The consensus among train crews was that a sudden emergency application from the rear could cause a breakaway (which is in fact not possible, as the cock does not apply the brakes solely to the rear car but rather uniformly along the full length of the train), and there was some evidence from previous accidents to validate such an opinion, however these were not involving the modern multiple-unit train design of which the Tangara is an example.
Since this derailment, CityRail training and operational procedures now emphasise the guard's responsibility to monitor the train's speed, and if necessary, open the emergency brake pipe tap to stop the train.
Changes implemented
All Sydney
Sydney ( ) is the capital city of the state of New South Wales, and the most populous city in both Australia and Oceania. Located on Australia's east coast, the metropolis surrounds Sydney Harbour and extends about towards the Blue Mountain ...
and Intercity NSW Trainlink
NSW TrainLink is a train and coach operator in Australia, providing services throughout New South Wales and the Australian Capital Territory, along with limited interstate services into Victoria, Queensland and South Australia. Its primary interc ...
trains now have an additional safety feature, which has been fitted since the accident. In addition to the deadman handle and foot pedal, the trains are fitted with "task linked vigilance" - which resets a timer every time the driver activates certain controls. If there is no change in control, a flashing lamp and then buzzer sound and the driver is required to acknowledge a vigilance button. If the train's driver does not use the controls and does not acknowledge the vigilance alarm, the vigilance system is activated and makes an emergency brake application. All trains have also been fitted with data loggers to record the driver's and guard's actions as they work the train, as well as the train's speed. Such a system had been fitted to G7, but was in the early stage of fleet roll-out, and hence had not been commissioned and switched on at the time of the accident.
Rescue workers who attended the scene were impeded from accessing the trapped passengers on the train because they did not have the keys required to open the emergency exit doors. Emergency exit mechanisms have all been modified, to allow them to be used without requiring a key. RailCorp
Rail Corporation New South Wales (RailCorp) was an agency of the State of New South Wales, Australia established under the ''Transport Administration Act 1988'' in 2004. It was a division under the control of Transport for NSW since the latter' ...
has installed internal emergency door release mechanisms on all new trains. However many passengers found their own way out since the train was broken into three pieces during the accident.
Automatic train protection
Automatic train protection (ATP) is a type of train protection system which continually checks that the speed of a train is compatible with the permitted speed allowed by signalling, including automatic stop at certain signal aspects. If it is ...
(ATP) could possibly have prevented the accident. Railcorp has tested ATP systems on the Blue Mountains line in western Sydney, and plans for ATP implementation across the Sydney Trains and NSW TrainLink Intercity/Regional networks are being formulated.
CityRail/RailCorp incorporated emergency door releases on the insides of the new Waratah trains as a result of the inquiries to this disaster, enabling passengers to open the doors themselves in case of an emergency, where the crew are incapacitated and the train is at a standstill.
The 2004 changes to medical assessments of rail workers were developed in response to the incident. Overseen by the National Transport Commission
The National Transport Commission (NTC), previously known as the National Road Transport Commission, is an Australian statutory body created to develop regulatory and operational reform for road, rail and intermodal transport.
Under Australia's ...
, Cardiac assessments are mandatory for certification and re-certification with a proscribed mandatory checklist as part of the national standard in the interest of ensuring public safety, the intended purpose of the health assessments whereas previously the health assessments did not have an occupational risk but a clinical focus.
References
External links
Special Commission of Inquiry into the Waterfall Rail Accident
{{2003 railway accidents
2003 in Australia
2000s in New South Wales
Derailments in Australia
Disasters in Sydney
January 2003 events in Australia
Railway accidents in 2003
Runaway train disasters
Railway accidents and incidents in New South Wales
2003 disasters in Australia