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Waterfall Train Disaster (system life cycle (operation (operation…
Waterfall Train Disaster
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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)
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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 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)
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Management
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design
inspection
the accident could have been avoided had a vigilance device been fitted to G7. (Mardon, 2014)
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system life cycle
operation
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operation management
Issues and findings related to people, workplaces & management
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commission
testing
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)
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concept
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emergency procedure
There was no co-ordination of these plans with emergency services. (Government of new south wales, 2005)
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)
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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)
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