Beresfield Accident Findings
Bob (gioia@fastlink.com.au)
Fri, 01 May 1998 01:43:11 +1000
Here is sa summery of the official report into the accident:
1) The train crew failed to comply with safety and signal warnings
before the crash.
2) The train crew was suffering from work related fatigue due to sleep
deprivation induced by their shift patterns.
3) The trains safety control system did not adequately protect against
reduced driver alertness and needs improving.
4) Defences to protect the train from human error had not been
established or were inadequate.
5) The system was entirely dependant on the train crew observing and
responding to signals.
6) A fatigue management program for train crews should be considered.
7) There was a lack of specific operating preceedures for train crews.
8)Permanent crew pairings are not recommended.
9) Ineffective radio communications contributed and could be improved by
the use of global positioning systems.
10) Conscern was raised that rail "incidents" are being under reported.
11) Better reporting systems are needed to identify human and system
weaknesses.
The Governments reply to the report is as follows:
A) $4.1 M to improve the track and signals around Beresfield as a part
of a $10 M Hunter rail infrastructure package.
B) A new radio system is to be installed in NSW trains to enable
communication with train controllers.
C) Plans to test a high tech automatic train stopping system in the
Hunter.
D) A review of Freightcorp and State Rail operating procedures to reduce
accident risk.
E) Appointment of a consultant to analyse effectiveness of Freightcorps
driver alert system.
F) Participation by Freightcorp in a national research study by the
South Australian Centre for Sleep Research to help improve rosters.
G) A review of rosters.
No doubt this report deserves comments by all in this newsgroup. Lets
go!
Bob