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- Rail Safety Investigation Final Report > Executive Summary
Waterfall Rail Safety Investigation Final Report - Executive Summary
At approximately 0714 on 31 January 2003, State Rail Authority
(SRA) passenger train service C311, a scheduled service from Sydney
to Port Kembla, overturned at high speed and collided with stanchions
and a rock cutting approximately 2 km south of Waterfall NSW.
The train was carrying 47 passengers and two crew. As a result
of the accident, the driver and six passengers were killed. The
four-car Tangara train, identified as G7, was extensively damaged.
The investigation found there was a high probability that the driver
became incapacitated at the controls as a result of a pre-existing
medical condition, shortly after departing Waterfall Station. The
train then continued to accelerate, out of control, with maximum
power applied. The deadman system and the guard were the designated
risk controls against driver incapacitation. Both controls failed
to intervene as intended and C311 overturned on a curve while travelling
at approximately 117 km/h. The train continued on its side for a
short distance until it collided with stanchions and a rock cutting.
The first and second carriages were righted by the collision. The
driver and six passengers were ejected from the train as a result
of the accident.
The immediate cause of the accident was the train exceeding the
overturning speed for the curve. The systemic causes of the accident
were the simultaneous failures of risk controls in the areas of
medical standards, deadman system and training.
Although G7 was fitted with two data loggers, they had not been
commissioned. Extensive investigation was therefore required, including
computer simulation, to provide an understanding of the conditions
that preceded the accident and the crash sequence. An underdeveloped
safety culture had resulted in failures in the application of the
published SRA Safety Management System by line management. SRA had
insufficient safety and risk management expertise and had not systematically
identified hazards to its operations or effectively controlled all
the risks that had been identified. It had a reliance on accident
trends to identify risks that needed to be controlled which demonstrated
a reactive approach to risk management.
The Rail Safety Regulator had been inadequately resourced to develop
an effective rail safety regulatory regime, and consequently had
not identified the risk management deficiencies that existed at
SRA. The investigation has made a number of performance-based recommendations
to address the systemic safety deficiencies identified in this report.
Full copy
of the report - 967 kb PDF
NSW Government's response to the report - Web
page | Word file
(86 kb)
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