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Australia: Rail crash inquiry reveals serious mechanical flaws
left uncorrected
By Barry Jobson and Terry Cook
2 July 2003
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Evidence presented to the judicial inquiry into the Waterfall
rail disaster in New South Wales, Australia has pointed to serious
long-term mechanical faults with the 15-year-old double-deck Tangara
passenger fleet that have been ignored by rail authorities and
the state government.
On January 31, a Tangara trainlabelled G7derailed
at high-speed outside Waterfall station, about 40 kilometres south
of Sydney, resulting in the death of the 53-year-old driver Herman
Zeides and six passengers. Simulated tests showed that the train
was travelling at 117 kph as it attempted to negotiate the bends
in a zone with a 60-kph speed limit.
In the aftermath of the disaster the NSW Labor government,
already under fire over the deteriorating state of the rail network,
sought to avoid responsibility by declaring the train mechanically
sound and attempting to direct blame toward the driver. Evidence,
however, points to the contrary.
In the early stages of the inquiry, several train drivers testified
that Tangara trains were prone to surginggathering
speed unexpectedlyand braking faults, which accentuated
the problem. Their testimony is consistent with statements by
passengers indicating that the train had speeded up alarmingly
as it entered the bends south of the station.
One driver described the particular TangaraG7as
unruly and having a mind of its own. Another,
Timothy Sharp, said he had experienced a pushing sensation
after applying the brakes when driving the train on January 10.
It was surging, he said. He only managed to control
the train by applying maximum brake pressure but the surging
returned as soon as he eased back on the brakes. Previously non-operating
motors at the rear of the train suddenly came to life, propelling
the Tangara forward.
Driver Randell Goddard testified to similar experiences with
the Tangaras, while another driver Mark Facey reported trains
surging as he attempted to bring them into stations. Evidence
was presented that a train had rushed forward, overshooting a
station and going through a red light, after the brakes were applied.
The inquiry was told that drivers reached an understanding
to avoid applying the emergency brake because the train sped up
for a few seconds before the brake became operational.
The most damning fact to emerge was that rail authorities ignored
repeated reports from drivers about these problems. Driver David
Johnson testified that he and fellow driver Don Millar reported
about 25 defects on the G7 over a three-year period. He said that
he had been disappointed by the response of State
Rail. Johnson said there was no feedback on any measures taken.
Often drivers who contacted the defects branch were abused.
The testimony from the drivers certainly warrants further investigation
into what was done about the reported faults. Such inquiries would
raise serious questions about the culpability, not only of State
Rail, but the Labor government, which has corporatised the public
rail system and subjected it to severe financial constraints.
Instead, the inquiry headed by Acting Justice Peter McInerney
has begun examining unsubstantiated allegations that Herman Zeides,
and rail drivers in general, engaged in unsafe practices.
The accusations emerged alongside the claim that Zeides may
have suffered a heart attack just prior to the accident causing
the train to run out of control. The issue was raised again even
though a post-mortem examination carried out immediately after
the crash failed to establish exactly what killed Zeides. Its
findings were declared by the Glebe Coroners Court to be inconclusive.
Dr Graham Peel testified in June that the drivers cardiovascular
system was diseased. Under questioning, he declared that Zeides
was most likely incapacitated by cardiac arrest before
the crash. But the possibility that Zeides suffered a heart attack
raises more questions than it answers.
The Tangara trains are equipped with a number of fail-safe
devices, including one known as a deadmans brake. These
are meant to activate the braking system and bring the train to
a standstill if the driver becomes incapacitated. The deadman's
pedal, for example, activates the brakes if the driver becomes
unconscious and his foot lifts from the pedal.
State Rail authorities attempted to show that drivers deliberately
circumvent these safety devices. On June 19, safety expert John
Gusselli claimed that drivers may disable the deadmans brake
by jamming a flagstick under the console. His only evidence, however,
was that, in the course of his inspections, he had had found black
marks under the console of 29 Tangara trains, including G7.
Gusselli suggested that in each case a gum-like substance may
have been used to jam a flagstick to hold down the deadmans
pedal. Without any corroborating evidence, he intimated that possibly
for the 15-year history of the Tangara fleet, some trains were
operating without a safeguard against an incapacitated driver.
He admitted, however, that he did not know if it was one
person who did it, or every driver in the fleet.
The media picked up on the Gussellis statements. In particular,
Murdochs tabloid, the Daily Telegraph, embellished
the story by making outlandish accusations that drivers read while
operating trains and are generally inattentive. No evidence was
presentedonly photographs of printed material lying on the
consoles of some trains.
The rail authorities, and no doubt the Labor government, had
hoped that Gussellis testimony would point to the conclusion
that Zeideswho was praised by fellow workers as a competent
and careful driverhad disabled the deadmans pedal
on the day of the disaster. However, all three flagstaffs on the
crushed Tangara were found intact on the floor of drivers
cabin. Gusselli admitted under cross-examination that if a flagstaff
had been jammed under the console at the time of the crash, it
would have been smashed.
But having eliminated the possibility that the deadmans
brake had been deliberately tampered with, the issue remained:
if Zeides had suffered a heart attack, why didnt the safety
brake work? Three reports by risk engineer Kevin Anderson, presented
to the inquiry on June 24, pointed to another possible mechanical
defect serious enough to cause the crash. Anderson had been retained
in 1992 to examine the braking system on the Explorer train, which
is similar to the Tangara. He had concluded that there was a danger
that a deadmans pedal could fail due to the passive weight
of the leg of an incapacitated driver.
Anderson testified to raising the same concerns in 1994 and
1999 in relation to the Tangaras and recommending the addition
of a vigilance control device to monitor if the driver
was alert. He stated that the train posed a significant
risk unless the back-up system was installed. His proposal
was dismissed by a rail steering committee, which insisted that
the motion of a moving train would be sufficient to dislodge an
unconscious drivers foot.
Driver John Kennedy told the Waterfall inquiry in late June
that he had refused to drive a train with a failed deadmans
brake, even though he feared being stitched up by
Cityrail for taking a stand. He said he reported the fault and
refused to continue driving, despite being ordered to do so. The
train was carrying 500 passengers at the time, including scores
of school children.
The evidence so far presented to the Waterfall inquiry points
to the opposite conclusion to that being pushed by the Carr government
and the media. Rather than an irresponsible driver being at fault,
everything points to mechanical defects that were well known,
had been reported to State Rail on a number of occasions and had
been ignored.
This is not just the responsibility of rail management but
of the Labor government which, in slashing costs, is compromising
public safety. The crash at Waterfall, like the Glenbrook rail
disaster in 1999, which claimed seven lives, is symptomatic of
a systematic rundown of maintenance, infrastructure and safety
standards.
See Also:
Australia: Seven die in rail
crash near Sydney
[5 February 2003]
Report into Australian
rail disaster shows government decisions undermined safety
[1 June 2001]
The New South Wales
rail systema disaster waiting to happen
[14 August 1999]
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