Waterfall train disaster
Encyclopedia
The Waterfall rail accident was a train
accident that occurred on 31 January 2003 near Waterfall
, New South Wales
, Australia. The train derailed
, killing seven people aboard, including the train driver.
at 6:24 am, departed Sydney Waterfall railway station
moving south towards Port Kembla Station
via Wollongong. At approximately 7:15 am, the driver suddenly suffered a heart attack
and lost control of the train. Consequently, the train was travelling at 117 km/h (72.7 mph) as it approached a curve in the tracks through a small gorge. This curve is rated for speeds no greater than 60 km/h (37.3 mph). The train derailed, overturned and collided with the rocky walls of the gorge in a remote area south of the station. It was reported that rescuers had to carry heavy lifting equipment for more than 1.5 kilometre (0.93205910497471 mi) to reach the site. Two of the carriages landed on their side 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. It was stated by the train guard
's solicitor that the guard was in a microsleep
for as much as 30 seconds just prior to the accident. The experienced human-factors accident investigator determined the organizational culture had the driver firmly in charge, making it psychologically more difficult for the guard to act. The guard in question had a history of not responding well to stress and refused to be interviewed by the investigator.
, to address problems when the driver becomes incapacitated. If the driver releases pressure from this brake the train will come to a halt.
CityRail
rolling stock
are often divided into sets of four carriages: two driver and two driven (trailer) carriages. Four car services consist of one set of four, six car services consist of a set of four driven and two driver carriages and eight car services are two sets of four carriages.
The G-set in question, numbered G7, was a four car Tangara set that was fitted with an AC drive system for evaluation purposes. There was a driver in the forward driver carriage and a guard in the rear driver carriage. 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 117 km/h (72.7 mph) as it approached the 60 km/h (37.3 mph) 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.
G7 was scrapped in 2005 due to the damage sustained in the accident; 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, was released in January 2004.
The inquiry found a number of flaws in the deadman's handle and facts related to the deadman's pedal:
Some of the technical problems included brake failure and power surge problems. After the accident these 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 used seldom because the train would accelerate between 5 and 10 km/h before the brake came into effect.
Official findings into the accident also blamed an "underdeveloped safety culture
". 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
, representing the guard on the train, Bill Van Kessel, said that Van Kessel was in a microsleep
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 that there had been attitudes that the driver was completely in charge of the train, that 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 tap. Apart from the driver being considered to be the sole operator of the train, the emergency brake pipe tap 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 and there was some evidence from previous accidents to validate this opinion.
Since this derailment, CityRail training and operational procedures now emphasise the guard's responsibility to monitor the train's speed, and if need be open the emergency brake pipe tap
to stop the train.
Rescue workers who attended the scene were impeded from accessing the trapped passengers on the train as 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 has installed internal emergency door release mechanisms on all the new trains.
Automatic Train Protection
could have prevented this accident. Railcorp has tested ATP systems on the Blue Mountains line west of Penrith
, and plans for ATP implementation across the CityRail network are being formulated.
CityRail/RailCorp has incorporated emergency door releases (EDR) on the insides of the new Waratah Trains
as a result of the inquiries to this disaster, enabling passengers open the doors themselves in case of an emergency.
Train
A train is a connected series of vehicles for rail transport that move along a track to transport cargo or passengers from one place to another place. The track usually consists of two rails, but might also be a monorail or maglev guideway.Propulsion for the train is provided by a separate...
accident that occurred on 31 January 2003 near Waterfall
Waterfall, New South Wales
Waterfall is a small suburb in southern Sydney, in the state of New South Wales, Australia. Waterfall is located 38 kilometers south of the Sydney central business district in the Sutherland Shire....
, New South Wales
New South Wales
New South Wales is a state of :Australia, located in the east of the country. It is bordered by Queensland, Victoria and South Australia to the north, south and west respectively. To the east, the state is bordered by the Tasman Sea, which forms part of the Pacific Ocean. New South Wales...
, Australia. The train derailed
Derailment
A derailment is an accident on a railway or tramway in which a rail vehicle, or part or all of a train, leaves the tracks on which it is travelling, with consequent damage and in many cases injury and/or death....
, killing seven people aboard, including the train driver.
Incident
On the day of the disaster, a Tangara intercity train service, set G7, which had come from Sydney Central StationCentral railway station, Sydney
Central Railway Station, the largest railway station in Australia, is at the southern end of the Sydney CBD. It services almost all the lines on the CityRail network, and is the major terminus for interurban and interstate rail services...
at 6:24 am, departed Sydney Waterfall railway station
Waterfall railway station, Sydney
Waterfall railway station is a Sydney railway station serving the suburb of Waterfall, New South Wales and is the last stop of the suburban section of the Illawarra line. Waterfall station also provides access to Camp Coutts, a large Scout campsite. The station opened in 1886, moving to its present...
moving south towards Port Kembla Station
Port Kembla railway station, New South Wales
-Transport links:Premier Illawarra runs four routes to and from Port Kembla railway station:*34 - to Wollongong*43 - to Dapto*65 - to North Beach*69 - between Westfield Figtree and Westfield Warrawong-Neighbouring stations:...
via Wollongong. At approximately 7:15 am, the driver suddenly suffered a heart attack
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
and lost control of the train. Consequently, the train was travelling at 117 km/h (72.7 mph) as it approached a curve in the tracks through a small gorge. This curve is rated for speeds no greater than 60 km/h (37.3 mph). The train derailed, overturned and collided with the rocky walls of the gorge in a remote area south of the station. It was reported that rescuers had to carry heavy lifting equipment for more than 1.5 kilometre (0.93205910497471 mi) to reach the site. Two of the carriages landed on their side 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. It was stated by the train guard
Conductor (transportation)
A conductor is a member of a railway train's crew that is responsible for operational and safety duties that do not involve the actual operation of the train. The title of conductor is most associated with railway operations in North America, but the role of conductor is common to railways...
's solicitor that the guard was in a microsleep
Microsleep
A microsleep is an episode of sleep which may last for a fraction of a second or up to thirty seconds. Often, it is the result of sleep deprivation, mental fatigue, depression, sleep apnea, hypoxia, narcolepsy, or hypersomnia...
for as much as 30 seconds just prior to the accident. The experienced human-factors accident investigator determined the organizational culture had the driver firmly in charge, making it psychologically more difficult for the guard to act. The guard in question had a history of not responding well to stress and refused to be interviewed by the investigator.
Causes of the accident
Tangara trains have a number of safety and vigilance devices installed, such as a deadman's brakeDead man's switch
A dead man's switch is a switch that is automatically operated in case the human operator becomes incapacitated, such as through death or loss of consciousness....
, to address problems when the driver becomes incapacitated. If the driver releases pressure from this brake the train will come to a halt.
CityRail
CityRail
CityRail is an operating brand of RailCorp, a corporation owned by the state government of New South Wales, Australia. It is responsible for providing commuter rail services, and some coach services, in and around Sydney, Newcastle and Wollongong, the three largest cities of New South Wales. It is...
rolling stock
Rolling stock
Rolling stock comprises all the vehicles that move on a railway. It usually includes both powered and unpowered vehicles, for example locomotives, railroad cars, coaches and wagons...
are often divided into sets of four carriages: two driver and two driven (trailer) carriages. Four car services consist of one set of four, six car services consist of a set of four driven and two driver carriages and eight car services are two sets of four carriages.
The G-set in question, numbered G7, was a four car Tangara set that was fitted with an AC drive system for evaluation purposes. There was a driver in the forward driver carriage and a guard in the rear driver carriage. 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 117 km/h (72.7 mph) as it approached the 60 km/h (37.3 mph) 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.
G7 was scrapped in 2005 due to the damage sustained in the accident; 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, was released in January 2004.
Systemic causes
It was reported that G7 was said to have been reported for technical problems as many as twelve times and had developed a reputation, amongst the mechanical operations branch, saying that these problems were "normal" for the set in question. During the six months up to the accident three reports of technical problems were made.The inquiry found a number of flaws in the deadman's handle and facts 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;
- the design of the deadman's pedal did not appear to be able to operate as intended with drivers of all shapes and sizes.
- marks near the deadman's pedal indicated that some drivers were wedging a conveniently sized signalling flag to defeat the deadman's pedal, in order to prevent their leg from crampCrampCramps are unpleasant, often painful sensations caused by muscle contraction or over shortening. Common causes of skeletal muscle cramps include muscle fatigue, low sodium, and low potassium...
ing in the poorly configured foot well and to give themselves freedom of movement in the cabin.
Some of the technical problems included brake failure and power surge problems. After the accident these 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 used seldom because the train would accelerate between 5 and 10 km/h before the brake came into effect.
Official findings into the accident also blamed an "underdeveloped safety culture
Safety culture
Safety culture is a term used to describe the way in which safety is managed in the workplace, and often reflects "the attitudes, beliefs, perceptions and values that employees share in relation to safety" .-Defining safety culture:...
". There has been criticism of the way CityRail managed safety issues, resulting in what the NSW Ministry of Transport
NSW Ministry of Transport
Transport New South Wales was the New South Wales state government agency responsible for coordinating public transport across New South Wales...
termed "a reactive approach to risk management".
At the inquiry, Paul Webb, Queen's Counsel
Queen's Counsel
Queen's Counsel , known as King's Counsel during the reign of a male sovereign, are lawyers appointed by letters patent to be one of Her [or His] Majesty's Counsel learned in the law...
, representing the guard on the train, Bill Van Kessel, said that Van Kessel was in a microsleep
Microsleep
A microsleep is an episode of sleep which may last for a fraction of a second or up to thirty seconds. Often, it is the result of sleep deprivation, mental fatigue, depression, sleep apnea, hypoxia, narcolepsy, or hypersomnia...
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 that there had been attitudes that the driver was completely in charge of the train, that 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 tap. Apart from the driver being considered to be the sole operator of the train, the emergency brake pipe tap 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 and there was some evidence from previous accidents to validate this opinion.
Since this derailment, CityRail training and operational procedures now emphasise the guard's responsibility to monitor the train's speed, and if need be open the emergency brake pipe tap
Pulled tail
Pulled tail is the act of a guard or conductor of a railway to apply the emergency brakes where something untoward has been noticed. This could be an excess of speed in a section of line known to have a lower speed, or strange noises and shaking that might indicate that the train has derailed or...
to stop the train.
Changes implemented
All CityRail trains now have an additional safety feature, fitted since the accident. As well as the deadman handle and foot pedal, the driver is now 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 a penalty brake application. All trains have also been fitted with data loggers that record the driver's and guard's actions as they work the train, as well as the train's speed.Rescue workers who attended the scene were impeded from accessing the trapped passengers on the train as 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 has installed internal emergency door release mechanisms on all the new trains.
Automatic Train Protection
Automatic Train Protection
Automatic Train Protection in Great Britain refers to either of two implementations of a train protection system installed in some trains in order to help prevent collisions through a driver's failure to observe a signal or speed restriction...
could have prevented this accident. Railcorp has tested ATP systems on the Blue Mountains line west of Penrith
Penrith, New South Wales
Penrith is a suburb in western Sydney, in the state of New South Wales, Australia. Penrith is located west of the Sydney central business district and is the administrative centre for the local government area of the City of Penrith...
, and plans for ATP implementation across the CityRail network are being formulated.
CityRail/RailCorp has incorporated emergency door releases (EDR) on the insides of the new Waratah Trains
CityRail A set
The CityRail A set or Waratah is a class of electric multiple unit operated by CityRail in Sydney, New South Wales, Australia. The train was named Waratah by the NSW Government after the flower of the same name, which is the state's floral emblem....
as a result of the inquiries to this disaster, enabling passengers open the doors themselves in case of an emergency.