Waterfall Train Disaster

People workplace and management

what happened?

On 31 January 2003, a four car Outer Suburban Tangara passenger train, designated G7, travelling along the South Coast line to Port Kembla derailed. (kerr, 2004)

7 passengers died.

The cause of the accident was that the train was at a high-speed rollover. G7 was traveling at approximately 117 km/has it entered the curve on which it derailed. The speed limit at that point was 60 km/h. (Government of new south wales, 2005)

staff

the accident occurred near waterfall station

Management

The train driver suffered a heart attack, collapsing onto a "dead man's pedal", which forced his commuter train to speed up and run off the rails (kerr, 2004)

the accident could have been avoided had a vigilance device been fitted to G7. (5)

organisational factors

job design

emergency response

driver safety system

a failure of the deadman system

system life cycle

operation

commission

mainanace

construction

concept

speed

overturned approximately 1.9 kilometres south of Waterfall railway station .

controls

effective system for identifying safety risk

emergency procedure

There was no co-ordination of these plans with emergency services. (Government of new south wales, 2005)

oil pressure

inspection

timetable

capacity

fuel

route plan

operation management

customer management

testing

safety

transport

machinery

manufacture

capacity

organisation

manufacture

Issues and findings related to people, workplaces & management

Post- mortem examination revealed that he had a 90 per cent blockage of the left anterior descending coronary artery. (Government of new south wales, 2005)

organisations management

cost

roles and responsibilities

The train driver,

The train driver, Mr Zeides, had a number of risk factors for coronary artery disease. (Government of new south wales, 2005)

training

The train driver, Mr Zeides, had an heart attack

tasks

training

Mr Zeides, inaction due to lack of training by the guard, William van Kessel, and a flawed deadman pedal, which is supposed to stop a train if the driver is incapacitated. (Mardon, 2014)

Mr Zeides, inaction due to lack of training by the guard, William van Kessel, and a flawed deadman pedal, which is supposed to stop a train if the driver is incapacitated. (Mardon, 2014)

design

inspection

Design failures

safety

The SRA failed to implement an engineering management system before manufacture of the Tangara trains commenced. (Government of new south wales, 2005)

failed to conduct a risk assessment of the deadman foot pedal. (Government of new south wales, 2005)



"Through the concept of safety we now have better knowledge and understanding of what to do in the workplace, and to ensure people are safe in what they do and the tasks they do and our role in it". (Government of new south wales, 2005)

system

The foot pedal was designed so that if too much or too little pressure was applied, the emergency brakes would be applied. (Government of new south wales, 2005)

The deadman system was designed to stop the train unless the train driver maintained continuous pressure on either a spring-loaded hand control or a foot pedal. (kerr, 2004)

There was a failure of the deadman system

Mr Zeides was using the foot pedal when he had a heart attack and that the foot pedal failed to operate as intended.

the system was suppose to prevent an accident of this kind if the train driver has a sudden heart attack. (Government of new south wales, 2005)

the accident could have been avoided had a vigilance device been fitted to G7. (Mardon, 2014)

testing

breaks

electrical

internal

external

passenger safety