Waterfall Implementation
What happened in the Waterfall Accident?
Just after 7am on 31 January 2003, a State Rail Authority (SRA) passenger service travelling from Sydney to Port Kembla overturned at high speed and collided with stanchions and a rock cutting approximately two kilometres south of Waterfall.
The train was carrying 47 passengers and two crew. As a result of the accident, the driver and six passengers were killed.
What was the role of the Special Commission of Inquiry?
Following the accident, a Special Commission of Inquiry (SCOI), led by retired Supreme Court Justice Peter McInerney, was established. Under its Terms of Reference the Special Commission was required to inquire into and report into:
- the causes of the railway accident at Waterfall and the factors which contributed to it
- the adequacy of the safety management systems
- any safety improvements to rail operations which the Commissioner considers necessary as a result of his findings.
How did the NSW Government respond to the SCOI?
On 22 February 2005 the NSW Government announced its formal response to the recommendations contained within the Final Report of the Special Commission of Inquiry (SCOI) into the Waterfall Rail Accident Volume 1 and Volume 2, published on 17 January 2005.
The legislative provisions necessary to implement the Commission's recommendations were enacted by the NSW Parliament via the Transport Legislation Amendment (Waterfall Rail Inquiry Recommendations Act) 2005. This Act addressed those recommendations concerning corporate governance arrangements. The remaining recommendations, which largely concern operational reform, do not require legislative amendment.
The NSW Government’s formal response to the recommendations made in the Final Report of the SCOI had considerable ramifications for industry, ITSRR and the Office of Transport Safety Investigations (OTSI).
The key elements of the Government's response to the Commission's Final Report on Waterfall, as far as it relates to safety regulation, are as follows:
- improvements in communication, training and equipment supporting the State’s emergency response capability
- better risk management and assessment by RailCorp, and the full integration of safety management within RailCorp’s overall corporate management systems
- installation of vigilance control on RailCorp operated fleets as a second engineering defence for driver incapacitation
- compatibility of communications equipment between all trains on the NSW rail network
- more effective processes for defect reporting and rectification, and the transfer of the defects unit of RailCorp its fleet maintenance division
- continuation of drug and alcohol testing programs
- regulations providing for improved periodical medical examinations across the rail industry
- train driver and guard training
- the development by RailCorp of a safety culture plan and program
- improved corporate governance with respect to safety, including clarity of safety accountabilities, safety training for senior management and the audit and review of safety management systems
- improved governance arrangements for rail safety regulation and investigation
- introduction of Automatic Train Protection
- replacement of RailCorp's Containment Policy
- improvement of location of trains
How is the implementation of recommendations being managed?
The implementation of the Government’s formal response to the recommendations of the SCOI is now occurring in a staged and sequential manner, building upon existing safety reforms in the NSW rail industry.
ITSRR is working with RailCorp (and the rail industry generally where relevant) according to an agreed implementation plan.
Substantial progress has been made in implementing the Government’s response to the Waterfall inquiry. The recommendations that have been closed to date have resulted in a range of important and practical improvements to current rail safety operational practices in NSW.
What is ITSRR's role in the implementation process?
ITSRR is responsible for overseeing the implementation of the Government's response to the recommendations contained within the Final Report of the Special Commission of Inquiry into the Waterfall accident.
This role includes verifying that recommendations have been effectively implemented and producing quarterly public reports detailing the progress being made by RailCorp, ITSRR and other agencies in the implementation of the Waterfall recommendations. ITSRR provides these reports to the Minister for Transport who then tables them in Parliament in order to enable scrutiny by members of Parliament and the public.
ITSRR continues to closely monitor progress in implementing the remaining recommendations in order to ensure long-term and sustainable improvements in rail safety in NSW.