Waterfall Rail Accident - Causes of The Accident - Systemic Causes

Systemic Causes

It was reported that G7 was said to have been reported for technical problems as many as 12 times, and had developed a reputation amongst the mechanical operations branch, saying these problems were "normal" for the set in question. During the six months up to the accident, three reports of technical problems were made.

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 and 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 some drivers were wedging a conveniently sized signalling flag to defeat the deadman's pedal, to prevent their legs from cramping in the poorly configured foot well and to give themselves freedom of movement in the cabin.

Some of the technical problems included 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 seldom be used because the train would accelerate between 5 and 10 km/h (3.1 and 6.2 mph) 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, resulting in what the NSW Ministry of Transport termed "a reactive approach to risk management".

At the inquiry, Paul Webb, Queen's Counsel, representing the guard on the train, said the guard was in a microsleep at the time of the question, for as much as 30 seconds, which would have removed the opportunity for the guard to halt the train. Webb had also proposed there had been attitudes that the driver was completely in charge of the train, and 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.

Prior to this derailment, neither training nor procedures mandated 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 provide the same degree of control over the automatic brake as a proper brake valve. The consensus among train crews was that a sudden emergency application from the rear could cause a breakaway and there was some evidence from previous accidents to validate this opinion.

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 stop the train.