SPECIAL COMMISION OF INQUIRY INTO WATERFALL RAIL ACCIDENT

BACKGROUND

The Waterfall train accident occurred on January 31, 2003 south of Waterfall station on the southern border of Sydney. The driver and six passengers were fatally injured in the accident. It was estimated that the Tangara train (G7) rolled over at a speed of 117 km/h on a left hand bend after the driver became incapacitated from a cardiac event. A Special Commission of Inquiry (SCOI) was established, he aded by the Honourable Peter McInerney . Dr Graham Edkins from Leading Edge Safety Systems and Dr Andrew McIntosh (formerly of the University of NSW) was engaged by the SCOI as expert human factors consultants to examine issues such as the effectiveness of th e train deadman design, a review of medical standards, fatigue management practices, driver and guard training, as well as full background histories on the driver and guard. Subsequently, Dr Graham Edkins was further engaged by the SCOI to head up the Safety Management Systems Expert Panel to undertake a review of the

THE RESULT

The SCOI was the largest transport safety inquiry ever undertaken in Australian history and led to widespread industry changing national reforms including more stringent health standards for rail safety workers, national model rail safety legislation, adoption of rail resource management training and was the trigger for several other industry improvement programs.

Waterfall Human Factors


Waterfall Lessons

SPECIAL COMMISION OF INQUIRY INTO WATERFALL RAIL ACCIDENT