1. Why is Rail Safety Important to me?
IRSC Vancouver Theme 1 - Components of a Robust Safety Management System
Why is Rail Safety Important to me?
Lessons from Accident Investigation
David Edwards
Executive Director
Australasian Transport Safety Solutions (ATRS) Pty Ltd
Vancouver, Canada
8 October 2013 1

2. Presentation Overview
Background The importance of people, culture & perception in managing safety risk
Case Study Robertson Rail Accident
Conclusion Why is safety important to me?
A personal experience !!!

3. Workplace Safety Perception
our individual differences influence how we perceive our work environment, the tasks at hand, our skills and capabilities
based on such perceptions, we make decisions on how we are going to behave
what level of safety risk are you prepared to accept?

4. Safety Risk Tolerance
Factors that shape our perception & tolerance of risk
general work environment
company leadership
management & supervisor role models
home & family life
sporting lifestyle
organisational culture

5. Safety Risk Behaviour
level of risk perception = level of safety behaviour

6. Human Risk Environment Factors
A number of factors contribute to how we view the work environment in terms of safety risk:
Memory – ability to learn varies from person to person, our perception of an event impacts on what we remember – our memory is biased
Experience – our memory is based on previous experience
Knowledge – people who take risks may not be less knowledgeable
Mood – our disposition affects how we function
Work stress – time pressure & work load
Group pressure – perception also applies to groups
Risk exposure – if we believe a risk is controlled, we may lower our risk rating & increase our risk taking behaviour
Workplace safety performance – no safety incidents = safe workplace?

7. Safety Value The Importance of Values in Reducing Risk
The extent of risk taking ultimately depends on the values that prevail, not the safety technology available (Wilde – Target Risk )
Both personal values & organisational values
What are your safety risk values?

8. NSW Southern Highlands Australia 19 May 1998 “my safety values”
Case Study
Robertson Accident
NSW Southern Highlands
Australia 19 May 1998
“my safety values” 8

9. Robertson Accident Site
Moss Vale Rail Line
From Wollongong
Illawarra Hwy
Old Road Bridge 9

10. Incident Background
Railway construction contractor laying concrete sleepers for track upgrade
Redundant 1928 road overbridge too low to accommodate added ballast
Bridge deck & piers removed
Formation adjacent to bridge abutments lowered to improve drainage
On 19 May 1998 a bridge abutment collapsed onto rail track after period of rain
In darkness and fog, freight train hit obstruction & locomotive rolled over hitting adjacent abutment of the new bridge
Train speed at time of collision = 34 kph
Two train drivers killed 10

11. The Train Locomotives 3 x NR Class (NR3/NR26/NR57)
GE-9 4,000 hp 16 cyl
130 tonnes
22 metres in length
120 in class
Two Driver Crew
Train
Train No.1BY4
Port Kembla to Whyalla
Wagons = 26 x RCGX & RCGF
Loading = Jumbo Coil Steel
Total trailing load - 1,672 tonnes 11

12. Sequence of Events

13. Bridge Superstructure
Sequence of Events
Bridge Superstructure
Removed for Vertical
Clearance

14. SeSequence of Events
Drains Lowered
Adjacent to Abutments

15. At 0400 Hours on 19/05/98 Undermined Abutment Collapses onto Track
& Hit by Freight Train

16. Collapsed Abutment 16

17. Opposite Abutment Wall (before)17

18. Opposite Abutment Wall (after)18

19. A Tragic Accident Site 19

20. Locomotive Cab Condition20

21. Why did Locomotive Roll Over?21

22. What Crash Protection? 22

23. Other High Risk Locations23

24. Contributing Factors
Previous vertically integrated NSW Government rail authority broken up with part privatisation in a new disaggregated rail environment
Stakeholders included: Network Manager (Rail Access Corporation) Network Maintenance (Rail Services Authority) Use of contractors for maintenance projects Multiple Train Operating Companies
Little or no engineering design, control, supervision (cost driven)
No risk assessment conducted
No interface plans between stakeholders
No clear responsibility or accountability and no understanding of safety culture
information withheld from formal investigation 24

25. In Summary
I believe there are four key elements that drive our personal perception of safety risk, they are our…
Attitudes – Values – Beliefs – Behaviours
The Robertson derailment in 1998 was for me a life changing experience that altered my attitudes, values, beliefs, and behaviour, the cause of which I now share with you !!! 25

26. Why is Safety Important to Me?
Incident Day 4
Unexpected family visit to crash site 26

27. Rest in Peace John Anderson & Wayne Dunstan
Robertson – 19/05/98
Rest in Peace John Anderson & Wayne Dunstan 27

28. Thank You “If you think safety is expensive, try having an accident”28