JUSTICE Peter McInerney criticises management for a collective failure to train and supervise operating staff in his report on the tail-end collision which killed seven and injured 51 at Glenbrook in New South Wales on December 2 1999 (RG 4.00 p212). He says 23 factors combined to cause the accident, but no-one will face criminal charges. The second stage of his inquiry, considering the implications for rail safety generally, commenced on June 8.

Signal 41.6 east of Glenbrook had failed to red, forcing David Willoughby, co-driver on the eastbound Indian Pacific, to seek authority from Penrith signalbox to pass it. He was asked to report his exit from the block section, but could not do so because the telephone at 40.8 had been damaged. The signallers awaiting his call assumed he must have seen 40.8 at green and driven on. He had not, but there was no train location indicator in the box.

Kevin Sinnett, driving the 06.39 double-deck interurban EMU from Lithgow to Sydney, was advised by senior controller Michael Browne at Sydney Central station that 41.6 was red, but ’it’s on auto so trip past it.’ At 08.12, Sinnett called up Penrith box from Glenbrook station and asked ’I’m right to pass it, am I?’, to which signaller Mulholland replied ’Yeah mate, you certainly are.’ Sinnett was rounding a blind curve at 50 km/h when he saw 100m ahead a motorail wagon at the rear of the Indian Pacific, which he hit at 37 km/h.

McInerney was highly critical of the ’undisciplined and colloquial way important matters relating to rail safety were communicated.’ There can be no question that many operators compare badly to airlines in this respect, and it is a failing for which there is no excuse. McInerney noted that ’as soon as an event occurred which tested their knowledge of safe working procedures, the train controller, the signaller, and the driver of the interurban were all found wanting. This reflects badly on their employer and the systems for training, supervision and recertification.’