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