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Cairns Tilt Train Derailment (People (Drivers were competent, experienced…
Cairns Tilt Train Derailment
Workplace
Workplace Factors
Accident occurred between Bundaberg and Gladstone - Emergency services took 45 minutes to reach scene and treat the injured
Accident scene accessible by local road
Equipment Design
On-board Vigilance System did not detect any driver fatigue/lack in responsiveness
Automatic Train Protection (ATP) not implemented on Tilt Trains despite availability
Emergency lighting and equipment post accident was ineffective
Final report showed no indication of faulty signals, or critically failing systems within the train
Work Environment
Moon had set below horizon this night, meaning no natural illumination of surroundings
Outside temperature 24.5 degrees, not enough to cause overheating or freezing up of tracks/engines
Due to poor illumination of surroundings, unable to recognize any landmarks to indicate their geographical location
Management
Organisational/System Factors
Management passed decision not to implement ATP's as current procedures were considered enough protection
No safeguards/rules in place to ensure drivers do not leave cabin when approaching curves or reduced speed zones
Policy to run emergency safety videos each time passengers board train proved valuable - no fatalities
Job Design
Drivers expected to run trains as close to schedule as possible - upkeep of reputation and passenger satisfaction (No fines for being behind schedule though)
Information Transfer
Speed sign appeared very close to bend, may not have been enough reaction time for driver to act
Rostered crew changeover took place in Bundaberg, previous crew did not report any note-worthy occurrences
People
Drivers were competent, experienced and well trained
Reasonable knowledge of route
Driver distracted when reaching for his bag to take food out, did not see speed sign
Co-driver was in rear vestibule making coffee at time of derailment
Passengers - No fatalities
Both drivers had started shift in Bundaberg (40 minutes prior to derailment)
