AGY-4101 | Special Commission of Inquiry into the Waterfall Rail Accident

Full description

At approximately 7:14am on 31 January 2003, a four car Outer Suburban Tangara passenger train headed for Port Kembla left the track and overturned at high speed on a curve 1.9 kilometres from Waterfall railway station. (1)

A Special Commission of Inquiry headed by the Honourable Peter Aloysius McInerney was established on 2 February 2003 by the New South Wales Government to investigate the accident in which the train driver and six passengers were killed. (2) The Honourable Peter McInerney had previously headed the Special Commission of Inquiry into the Glenbrook Rail Accident that occurred on 2 December 1999.

Under Letters Patent issued on 3 February 2003, and varied by Letters Patent issued on 28 May and 29 October 2003, the Commission was to inquire and report to the Governor in two stages on the following matters:

Stage 1
1) The causes of the railway accident at Waterfall on 31 January 2003 and the factors which contributed to it;
Stage 2
2) The adequacy of the safety management systems applicable to the circumstances of the railway accident; and
3) Any safety improvements to rail operations which the Commissioner considers necessary as a result of his findings under matters (1) and (2). (3)

The Letters Patent declared that sections 22, 23, and 24 of the Special Commissions of Inquiry Act 1983 shall apply to and in respect of the Special Commission of Inquiry. (4)

By Instrument of Appointment dated 10 February 2003, Peter Michael Hall QC, Christopher Thomas Barry QC, and David Cowan were appointed by the Attorney General as Counsel Assisting. Originally the Commission was to deliver an Interim and Final Report to the Governor by 30 April 2003 but this was changed to 29 October 2004 by Letters Patent dated 28 May and 29 October 2003, and 28 April 2004. (5)

The Waterfall Special Commission of Inquiry sat for the first time on 14 February 2003 and directions were given for the conduct of the public hearings. The Commission was unable to function properly until its office premises became available on 3 March 2003. (6) The Commission’s hearings were conducted in the former HIH Insurance Royal Commission hearing room in Sydney which avoided the need for a special hearing room to be established with appropriate electronic facilities, including real time transcript facilities. (7)

Unlike the Glenbrook Special Commission of Inquiry, the Waterfall Inquiry was unable to undertake continuous hearings due to the need to ensure that technical investigations and analyses could be properly undertaken and completed prior to the leading of evidence in the hearing. Consequently the public hearings were held on 77 days between 1 April and 1 September 2003. (8)

Whenever possible, evidence was given orally rather than by the tender of written statement. After hearing the evidence of factual and expert witnesses, the Commissioner heard submissions from counsel for the parties and then adjourned to prepare his Interim Report. (9)

The Commission’s Interim Report was handed down in January 2004. The Commission excluded the following three matters as factors that caused or contributed to the accident:

1) deliberate conduct by the train driver;
2) any defect in the truck or associated infrastructure;
3) any malfunction or defect in the train, other than the deadman system. (10)

The Interim Report identified twelve factors that directly or indirectly caused or contributed to the accident. (11) Some of these factors had numerous sub-causes. The Commission’s main determinations were that the driver had suffered a sudden cardiac arrest and was therefore incapacitated and not in control of the train. The deadman system that is designed to cut power and apply the automatic brake if the driver is incapacitated failed because the static weight of the driver’s legs was enough to keep the deadman pedal in the set position after he collapsed, thereby preventing an emergency brake application. (12)

After the findings of the Commission’s inquiry into its first term of reference were reported in the Commission’s Interim Report, the Commission then moved on to its second phase (second and third terms of reference). As stated earlier, Stage two of the Inquiry required the Commission to inquire and report on the following: the adequacy of the safety management systems applicable to the circumstances of the railway accident; and any safety improvements to rail operations which the Commissioner considers necessary as a result of his findings. (13) Stage two was still in progress in September 2004.


ENDNOTES
1. Interim Report of the Special Commission of Inquiry into the Waterfall Rail Accident, January 2004, p.1.
2. loc. cit.
3. loc. cit.
4. loc. cit.
5. loc. cit.
6. ibid., p.2.
7. ibid., p.10.
8. ibid., pp.9-10.
9. ibid., p.11.
10. ibid., p.363.
11. ibid., pp.363-366.
12. ibid., p.363.
13. ibid., p.366.