Evidence at Australian rail disaster inquiry reveals chaotic safety system
4 March 2000
The official inquiry headed by Acting Justice Peter McInerney into the rail disaster at Glenbrook, near Sydney, on December 2, has barely entered its third week. Yet evidence has already emerged that chaotic safe running procedures and an antiquated system of tracking trains were bound to produce a major accident sooner or later.
Seven people, including a five-year old boy, were killed and 51 other passengers injured, when an inter-city train travelling to Sydney ploughed into the rear of the 400-metre long Indian Pacific after being allowed to proceed through a red stop signal one kilometre east of Glenbrook station on the Blue Mountains line.
Last week the inter-city driver Kevin Sinnett, 55, told the inquiry that he had been given clearance to proceed through the red light (signal 41.6) by the signalman at the Penrith signal box, Damian Mulholland, and by Michael Vincent Browne, the senior controller at Sydney's Central Station.
The inquiry heard tapes of both communications. At about 8.12 am, just prior to the inter-city train arriving at Glenbrook station, Browne informed Sinnett that signal 41.6 was showing red. “It's on an auto (automatic signal) so trip past it.” Minutes later after pulling into Glenbrook, Sinnett contacted the signal box at Penrith on the train's two-way communication system to check if it was OK for him to proceed through the red signal. “I'm alright to go past it, am I mate?” he asked. “You certainly are,” Mulholland replied.
Only minutes before Sinnett passed through the red light at Glenbrook, the driver of the Indian Pacific, David Willoughby, had been cleared to proceed through 41.6 after being held up for several minutes while using a trackside phone to contact Penrith. He was asked to report to back to Penrith if the next signal (40.8) was showing red but could not do so because a button on the trackside phone was broken and the equipment would not work.
In all, the Indian Pacific was held up for over four minutes at signal 40.8, reducing the distance between it and the oncoming inter-city train.
When Willoughby failed to phone in, both Browne and Mulholland presumed that signal 40.8 was on green and the line in front of the inter-city train was clear. Both testified that Sinnett had no way of knowing that the Indian Pacific was barely moving just ahead of him. When the Indian Pacific finally came into view as the inter-city train rounded a bend, Sinnett had less than 100 metres to halt his train.
Sinnett testified that he had never been trained in the use of the train's emergency brake, commonly known as the dead-man's handle, or informed what distance it took to stop a train in an emergency.
Despite this evidence there is a clear tendency to steer the inquiry towards finding that a major cause of the crash was “driver error”. Under heavy cross-examination by Christopher Barry QC, the counsel assisting the inquiry, Sinnett admitted that he had mistakenly broken safety regulations on the day of the accident by driving with caution (about 42 km/hr) instead of “extreme caution” (about 20 km/h) after passing through the red light. Even so, the inter-city train driver maintained he believed at the time that he had followed regulations.
During his examination of Sinnett, Barry produced the State Rail regulations stating that “a driver must exercise extreme caution when passing a signal at stop... and be prepared to stop short of any obstruction.” “What I am suggesting is that you did not do that on this occasion,” Barry said. “On this occasion, no, I did not,” Sinnett answered. However, even Justice McInerney later admitted that he was concerned over the “ambiguous nature of the regulations governing the procedures for red signals”.
This line of questioning downplays the circumstances that combined to produce the disaster at Glenbrook and serves to deflect from an examination of the underlying causes. For example, why were both drivers and signalmen on the stretch of line in question, between Glenbrook and Lapstone, forced to rely on such haphazard and archaic means to determine if the line was clear?
Not only are trackside phones open to vandalism and prone to breakdown, but also the particular stretch of line in question is known as the “dead hole” because deep rail cuttings make it notoriously bad for establishing communication by two-way radio or mobile phone.
One reason for the reliance on direct communication between the driver and the Penrith signal box was revealed in damning evidence given by Glenbrook station master William Higgins. He told the inquiry that the station once had a control room with an electronic monitoring system that could track the movement of trains on the line both east and west of the station, but this had been closed down by State Rail in 1994. If the system had still been operative it would have shown that the Indian Pacific was stationary at signal 40.8, enabling him to intervene and hold back the inter-city train.
An obvious question arises. Knowing the extreme difficulties with any form of communication on this section of line, why did State Rail dispense with the old tracking system at Glenbrook and why had no attempt been made to replace it with a new upgraded system in almost six years?
Browne, the chief controller of the Sydney rail network, told the inquiry it was a “disgrace” that trains could not be accurately tracked through the Blue Mountains because of the many “black holes” that existed along the line. Browne said he was under constant pressure to ensure trains ran on time but train movements in that section could only be plotted on paper.
Browne suggested several ways to make the system safe. They included a modern electronic signal board to track the movement of trains, and reliable and speedy radio communication with drivers.
There is another pressing question that remains to be answered, which has not yet even been raised. Why are signals throughout the NSW rail system habitually showing red when there is no obstruction on the line ahead? Prior to the inquiry, the Rail Access Corporation, which manages the rail network, reported that there had been 40 reported occasions of signal failure in the Sydney network in the previous 10 months, with trains instructed to proceed through red lights. There were 33 reported incidents of “Signals Passed at Danger” in 1996-97, rising to 37 in 1997-98.
The responsibility for the tragic crash at Glenbrook rests not with the drivers and signalmen but with successive state governments, which have slashed spending and jobs in the State Rail system over the past two decades resulting in signaling and safety systems that are antiquated and poorly maintained.