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Waterfall - Politiet undersøger ulykkesstedet Waterfall jernbaneulykken skete den 31. januar 2003 ved Waterfall, New South Wales, Australien, da et tog afsporedes og væltede. Ved ulykken omkom 6 passagerer samt togets fører.

On the morning of the disaster, a Tangara intercity train service, set G7, departed the Waterfall railway station heading south towards Port Kembla via Wollongong. At approximately 07:15 the driver, Herman Zeides, suffered a heart attack and lost control of the train. As a result the train was travelling at 117 km/h as it approached a curve in the tracks through a small gorge, which was only rated for speeds up to 60 km/h. The train derailed, overturned, and collided with the rocky walls of the gorge. In addition to the seven fatalities, many more passengers were injured.

The subsequent official inquiry discovered that the deadman's brake had failed to function. It was also determined that the train guard, who should have applied the emergency brake, was in a microsleep for up to 30 seconds just prior to the accident.

Causes of the accident

Tangara trains have a number of safety and vigilance devices installed in order to address problems where the driver became incapacitated, such as a deadman's brake system. If the driver releases pressure off this brake, the train comes to a halt.

CityRail rolling stock are often divided into sets of four carriages, two driver and two driven (trailer) carriages. Four car services consist of one set of four, six car services consist of a set of four and two driver carriages, and eight car services are two sets of four carriages.

The G7 in question was a four car Tangara set that was fitted with an AC drive system for evaluation purposes, with a driver in the forward driver carriage and a guard in the back driver carriage. For this service, the guard, who could have applied the emergency brake, and the deadman's brake were the main safety mechanisms in place.

The train was later found to be travelling in excess of 117 km/h as it was approaching the 60 km/h curve where the accident occurred. One passenger stated that it felt closer to 200 km/h. Neither the deadman's brake nor the guard had intervened in this situation, and this excessive speed was found to be the direct cause of the accident. Training of the staff of the train was also found to be a contributing factor in the accident.

G7 was scrapped in 2005 due to the damage sustained in the accident; all four cars were beyond repair.

These were the official findings of the NSW Ministry of Transport investigation to the accident. A report into the accident, headed by Commissioner Peter McInerney, was released in January 2004.

Systemic causes

It was also reported that the G7 set in question was said to have been reported for technical problems as many as twelve times, and had developed a reputation amongst the mechanical operations branch, saying that these problems were „normal“ for the set in question. In the six months up to the accident, three reports of technical problems were filed.

The inquiry found a number of flaws in the deadman's handle and facts related to the deadman's pedal: * the dead weight of the unconscious overweight driver appeared to be enough to defeat the deadman's pedal; * the design of the deadman's pedal did not appear to be able to operate as intended with drivers of all shapes and sizes. * marks near the deadman's pedal indicated that some drivers were wedging a conveniently sized signalling flag to defeat the deadman's pedal, in order to prevent their leg from cramping in the poorly configured foot well.

Some of the technical problems include brake failure and power surge problems. After the accident, these were often blamed by some for being the cause of the accident. Many of the survivors of the accident mentioned a large acceleration before the accident occurred. Furthermore, there was an understanding that the emergency brake should be seldom used because the train would accelerate between 5 and 10 km/h before the brake came into effect.

Official findings into the accident also blamed an „underdeveloped safety culture“. There has been criticism of the way CityRail managed safety issues that arose, resulting in what the NSW Ministry of Transport called a „a reactive approach to risk management“.

At the inquiry, Paul Webb, Queen's Counsel, representing the guard on the train, Bill Van Kessel, said that Van Kessel was in a microsleep at the time of the question, for up to 30 seconds, which would have removed the opportunity for the guard to put the train to a halt. Webb had also proposed that there had been attitudes that the driver was completely in charge of the train, that speeding was not an acceptable reason for the guard to slow or halt the train, which would have been a contributing factor in the accident.

(It's worth noting however, that prior to this derailment, neither training nor procedures called for the guard to exercise control over the speed of the train by using the emergency brake pipe tap. Apart from the driver being considered to be the sole operator of the train, the emergency brake pipe tap does not offer the same degree of control over the automatic brake as a proper brake valve. The consensus among traincrew was that a sudden emergency application from the rear could cause a breakaway, and there was some evidence from previous accidents to support this view.

Since this derailment, CityRail training and operational procedures now emphasise the guard's responsibility to monitor the train's speed, and if need be open the emergency brake pipe tap to bring the train to a stand.)

Similar accidents

To the extent that the Waterfall accident occurred because of a very sharp curve (with a very low speed limit), the following accidents have similarities, and lessons to be learned:

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