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images (SYSTEM LIFE CYCLE (CONCEPT AND DESIGN (Controls (Controls on…

- - - - Only rarely completing a safety briefing, nobody designated to complete the brief
        
        Critical information regarding situational awareness was not provided which led to the deaths of Mr Adams and Mr Watkins
    - - Did not perform daily service checks because it was too time consuming
        
        Performed 'tick and flick' rather than checking all items on checklist
        
        Led to not fixing defective lighting which contributed to the deaths of Mr Adams and Mr Watkins
      - PEOPLE/COMPETENCY/ LEADERSHIP FAILURE
  - - - Lack of vigilance while working
        
        Both crew members wore orange when it was required to wear safety yellow
        
        Were distracted by oncoming train
        
        Must not rely on anybody else to give warnings as stated in the safety Manuel
        
        Overall, these factors led to the death of both crew members
    - - Was operating the track machine
        
        Did not following the reversing speed limit
        
        travelled at 20km/h the speed limit is 10km/h
        
        Dramatically limited the time the crew members had to see the track machine coming gin their direction
        
        Only scanned rear camera once
        
        Was the only form of vision
        
        If he regularly checked the camera he may have spotted the crew members directly in the line of travel and prevented the collision
        
        PEOPLE/COMPETENCY FAILURE
        
        Did not operate the machine from the lead cab
        
        Was not travelling in the direction of sight
        
        Could not see Mr Adams or Mr Watkins
        
        Resulted in him being unaware and colliding with them
    - - Returned to his car to perform administrative tasks
        
        Switched off communication so he could complete these tasks
        
        Did not perform supervisory role after directing the two workers to complete a task without communication by turning off his own communication to the machine
        
        Could not notify the operator where the workers were which may have prevented the collision
        
        Did not advise the site groundsman Mr Carter to dismount the machine after getting water
        
        Nobody in a position to see the crew members
    - - Left his position to get a drink of water off the track machine, to which he stayed on board
        
        Had a clear repsonsibility to be located on the ground which he wasn't
        
        Would have seen the crew members if he was on the ground in time to prevent the collision
- - - - Mr Williams was in the cab facing away from the crew members meaning it sounded in the opposite direction
        
        Had no control to use the horn for both directions
        
        Was not loud enough to overpower the passing train
    - - Additional cameras, such as another that is constantly zoomed in to see distant objects would have been beneficial
      - DESIGN FAILURE
  - - - The working environment was extremely noisey due to a passing coal train
        
        Drowned out the horn Mr Williams sounded in attempt to notify everyone about the track machine moving
    - - Other than Mr Adams and Mr Watkins, all other staff were not in their designated positions
- - - - Some of the crew members had worked a substantial amount of hours in the days prior to the accident
    - - Mr Kapernick and Mr Carter had not been given a 10 hour break
        
        Their roles were important in the crew and fatigue may have been a factor
    - - Nobody was designated to complete a safety briefing, it was up to anybody that felt like it otherwise one would not take place
    - - Although there was supervision, Mr Williams was fatigued and complexity other administrative duties.
        
        The crew would have benefited from having another supervisor there fully focused on the task at hand
        
        PEOPLE/MANAGEMENT FAILURE
  - - - Minimal instructions were given to the crew members, As the supervisor Mr Kapernick should have given instruction to Mr Williams regarding being in the correct cab and Mr Carter for being out of position
    - - There was a general lack of commutation, Mr Adams and Mr Watkins had no way to contact anyone and their supervisor switched off all communication to complete other work. Mr Williams had nobody to contact regarding his movements other than Mr Carter who was on board at the time
  - - - Did not follow any procedures correctly at the start of the day such as the safety briefing and the machine check
        
        Defective lights that were not picked up on
    - - Mr Williams had to complete administrative tasks while in the middle of his supervising role
        
        Another worker should have been provided if Mr Williams could not fully participate doing his role
- - - - Potentially language barriers
  - - - To maintain and fix train tracks that have been damaged over time
  - - - Required to fix train track where damage and wear and tear has occurred
      - Required to be used at multiple different destinations in a day
  - - - Availability of parts
  - - - Controls on machine did not identify an incoming collision with the workers
        
        Controls on machine did not identify bodies underneath the machine
    - - Limited flashing lights on the machine and the ones that were on there were faulty and broken
    - - Pneumatic horn only sounds in forward direction therefore Mr Adam and Mr Watkins would not of heard it as the machine was reversing as well as being next to a passing train
    - - Machine only has communication set up for internal communication, Mr Adams and Mr Watkins had no way to contact the Machine directly
  - - - Track machines can be reconditioned with new parts or disposed off without further use
- - - - Lazy careless culture of workers to not follow procedures such as changing to the lead cab and not giving a safety briefing
    - - Workers had no set roles in responsibilities in giving a safety briefing before the start of the days work
  - - - Policies
      - Procedures
      - Rostering
        
        Workloads
  - - - Were defective and unknown to the crew members as they "tick and flicked" through the checklist without checking each item
    - - Only sounds in the direction of travel closed to the lead cab
- - - - A track resurfacing crew arrived onsite at the Mindi siding to complete track resurfacing work using the Unimat Track Machine on the Down Line At Mindi through the turnouts at Points 11 A/B and 12 C/D
    - - Another worker, Mr Williams then became the sole occupant of the lead cab in the Track Machine. Mr Carter, the grounds person left the operating position at the rear of the track to get his water bottle from the toolbox area on board the track machine, he then stayed on board.
        
        A 1.9km triple header coal train passed the Track machine while Mr Adams and Mr Watkins were at the rear of the Track Machine.
        
        As the Locomotives of the train were passing the Track Machine, Mr Williams scanned the rear view cameras, sounded the pneumatic horn 3 times and commenced reversing the Track Machine unaware Mr Adams and Mr Watkins were on the track behind him.
        
        Mr Williams was Operating the Track Machine from the trailing cab (as it was now in reverse) which means he had no sight of the direction of travel and no other crew member was stationed in the lead cab. Mr Kapernick(the resurfacing supervisor) could not see the work sight due to the coal train blocking his view
        
        It is believed the workers were either resembling points 12 C/D or standing on the track facing the coal train. 23 seconds after Mr WIlliams began reversing the Track Machine Mr Adams and Mr Watkins were struck by the Track Machine.
        
        Unaware of the Collision Mr Williams kept reversing until alerted by an operator that saw their bodies under the Track Machine. Both Mr Adams and Mr Williams were confirmed deceased 21 Minutes after an ambulance crew arrived