Train derailment
Hazard: unsafe track condition
Threat: excessive train speed prevents stopping before unsafe track location
Threat: obstruction on track
Threat: inadequate rolling stock, track and signalling equipment maintenance
Threat: train driver training inadequate to respond to unsafe track condition
Threat: incorrect signal provided to train driver allows travel through unsafe track location
Threat: incorrect response from train driver to signal to avoid unsafe track condition
PB: preventative maintenance regime in place
PB: trained and competent maintenance personnel
PB: sufficient and quality spare parts
PB: maintenance monitoring/inspection program(s)
PB: continuous improvement program in place for maintenance regime
PB: maintenance regime developed in consultation with technical experts, vendors and suppliers
PB: driver training program in place
PB: ongoing assessment in order to maintain competency
PB: training program supported by qualified and experienced trainer/assessors
PB: training program continually updated to reflect technology and leading practice changes
Bow Tie Diagram : Granville Train Disaster
PB: driver adequately trained and competent
PB: driver not impaired (drug and alcohol policy)
PB: driver not fatigued (fatigue management policy)
PB: driver not impaired (routine medical process)
PB: driver adequately trained and competent
PB: guidelines in place for drivers regarding speeds throughout network
PB: work instructions available, updated and competency assessed
PB: engineered controls on locomotives (speed limited)
PB: work instructions available, updated and competency assessed
PB: central train control alert to excessive speed
PB: on-board alarm systems to alert drivers
PB: fault reporting processes and procedures in place
PB: central train control monitoring
PB: central train control alarm systems
PB: driver adequately trained and competent
PB: on-board and central train control obstruction detection systems in place (engineering control)
PB: leading maintenance practices and technology used to inform maintenance regime
PB: track inspection regime in place
PB: closed-circuit TV cameras covering network monitored from central train control
PB: emergency braking system fitted to locomotives and carriages/wagons
PB: driver adequately trained and competent
PB: clear driver line-of-sight maintained at all times, including adequate lighting on network
EF: derailed train impacts nearby infrastructure
EFB: take into account nearby infrastructure in track design and visa versa
EFB: take into account impact of maintenance on nearby infrastructure when operating rail network and visa versa
EFB: install physical barriers between operating rail network and nearby infrastructure where possible and practical to do so
Key: PB (protective barrier), EF (escalation factor), EFB (escalation factor barrier), CB (consequence barrier)
Consequence: passengers, employees, bystanders injured or killed
Consequence: immediate infrastructure, equipment or machinery damaged or destroyed
Consequence: nearly infrastructure, equipment or machinery damaged or destroyed
Granville disaster investigation identified poor track maintenance as the primary contributing factor to the event - dogspikes holding wooden sleepers in place had allowed movement of rail over time, thereby allowing excessive lateral forces (separation) of track as the train passed over it, causing the front right hand wheel of the lead locomotive to derail and carriages to follow (Halgren, 2015)
Consequence: significant negative media (reputation damage)
Consequence: significant psychological distress for emergency response personnel (ie. first responders)
CB: rail operator employees (particularly senior management) practised in emergency scenario response
CB: emergency response crews practised and trained in catastrophic scenario management (police, ambulance, fire and rescue etc)
CB: relationship with nearby hospitals established and maintained in advance of emergency
CB: responsible person and team appointed to co-ordinate all emergency response activities
CB: onlookers and members of the public kept out of incident scene so as not to escalate number of casualties
CB: emergency response equipment in place and maintained within rail operator organisation
CB: maintain sufficient contingency within operating train fleet (number of locomotives and carriages)
CB: maintain sufficient spare parts
CB: ensure adequate levels of insurance are maintained
CB: maintain relationships with other rail providers to potentially assist in the event of a catastrophic scenario in terms of supplying equipment and trained personnel
CB: devise and maintain alternate route options to allow for recommencement of operations when safe to do so
CB: work with other agencies and neighbouring businesses in order to risk assess potential catastrophic scenarios
CB: ensure all media communications are directed through communications team
CB: focus on care for families and victims of accident
CB: appoint liaison officers to work with specific family and victim groups
CB: ensure all forms of media are addressed (ie social, electronic, newsprint, TV)
CB: work with external agencies to ensure professional support is provided to personnal
Consequence: significant psychological distress for employees, victims and their families
CB: establish relationship with professional psychological support provider before a catastrophic scenario
CB: ensure support is offered immediately and on an ongoing basis for all groups
CB: relationship with external emergency organisations established and maintained in advance of emergency
Consequence: significant financial impact or loss
CB: ensure adequate insurance is in place prior to an accident
CB: ensure dedicated team appointed to manage recovery activities with sufficient resources and experience
CB: seek external assistance from specialists to assist recovery team in order to minimise rebuilt time
CB: appoint dedicated personnel/team to liaise with other agencies in co-ordination of recovery effort