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PreMiSTS 1997 Granville Rail Disaster - Coggle Diagram
PreMiSTS 1997 Granville Rail Disaster
People
Inadequate standards for training.
Understaffed
Fettlers being killed on the lines as they are unaccompanied by a flagman.
Adequate maintenance is not being kept, endangering commuters and workers.
high workload and over time increases the risk of fatigue in workers.
Poor fastening of the track caused it to spread.
Bridge was not build to standard.
Philp Shirley instructed staff to maintain the tracks at their existing state.
The tracks were not in satisfactory condition to start with
Lack of experienced staff and training
Technology
Lack of government grants
Only providing funding for the status quota of the track workers
Not for repairing the damage.
Limited resources
Infrastructure
Prolonged use of unmaintained tracks
The track was poorly fastened and badly aligned
Lack of availability of resources
The bridge was not designed to stand on one set of trestles; causing the collapse.
The tracks spread wider than standard gauge
The base of the bridges deck was one metre lower than the road so concrete was added on top to make it level with the road. The excess weight contributed to the destruction of the carriages.
Processes
The NSW labour government limited the investigation into the Granville train disaster, under section 63 of the railways act
Staff were not fully informed of developments in track inspection and maintenance operations.
Lack of track inspections and maintenance
Resources were not readily available
Training
Staff
Equipment
Knowledge
Staff were unable to comply with safety procedures
Insufficient checks/ reporting mechanisms in the levels of orginisation to identify missed inspections
Building the bridge to standard was not followed, in attempts to mend the mistake concrete was added to build the bridge up to standard, making it much heavier and still lower then the standard.
Bold Street bridge had had derailments on the same section of track by a locomotive in 1967 and a loaded coal wagon in 1975.
Track maintenance did not improve after these events
There was no clear or definite policy regarding the frequency of gauge measurements, particularly tracks leading to points
Goals
To keep things running at minimal costs
Low standard of training
Poor track conditions
Limited staff
Culture
Tolerance of poor standards
Staff not being informed of track maintenance and inspections
Ignoring past crashes on the same section of track
Safety concerns were ignored when brought up
Governments rejection of funding and staffing requests
Complacency