Waterfall exposes safety management failings
TWO senior managers in RailCorp have been sacked and others faced the prospect of disciplinary action following publication on January 15 of Commissioner Peter McInerney's interim report into a derailment at Waterfall in New South Wales on January 31 2003. Seven died and 42 were injured (RG 3.03 p122).
He concluded that the deadman's pedal failed to apply the brakes when driver Herman Zeides became unconscious following a cardiac arrest shortly after leaving Waterfall at 07.12. The Tangara EMU accelerated for 2 km down a gradient and rolled over against a rock face when it entered a 50 km/h curve at 117 km/h.
McInerney identified two secondary causes. First, the guard should have realised something was wrong and applied the emergency brake, but he did not do so because over-speeding was common and he had not been trained adequately. Indeed, 'the concept of joint crew responsibility for train safety was not well understood.' The second cause was inadequate monitoring of the driver's health. Zeides had a history of heart problems, high cholesterol, drank heavily at weekends and was overweight.
But the main reason for the sackings was a failure by management to take any effective action on several reports that the deadman's pedal did not operate reliably when the driver fell asleep or became unconscious. A State Rail Authority driving instructor reported in 1988 that a driver could wedge his foot between a heater and the pedal so that it stayed down without effort, a fact that was subsequently confirmed by three successive safety reports.
But McInerney said safety management processes were so inadequate that the reports were filed and forgotten. Even an incident in Victoria involving a deadman's pedal 'remarkably similar to that fitted to Tangara trains' was ignored, and 'the standard response was that such an accident could not occur in NSW'.
NSW Premier Bob Carr said on January 15 that none of SRA's seven CEOs nor the three transport ministers who held office between 1988 and 2003 were told about the problem. He also announced that the Tangara fleet is to be fitted with vigilance devices during the coming year.
McInerney is to issue further reports by April 30 on the adequacy of RailCorp's risk management and what further safety improvements are needed such as better crashworthiness.