The Guardian 2 February, 2005
Waterfall inquiry: Government
"should be held accountable"
The final report from the inquiry into the January 2003 Waterfall rail disaster south of Sydney, in which seven people were killed, has identified the lack of a proper culture of safety. In the 900-page report, commissioner Peter McInerny, noted that rail workers were constantly blamed for shortcomings in safety in the NSW railways and that the Carr government should be held accountable for the lack of safety in the system.
The report warns that further accidents are likely because of a failure to implement safety reforms. The "blame-the-workers" approach is reflected in the regime put in place in August 2003. Under new regulations 31,000 random alcohol tests have been carried out on rail staff. Only 35 positive readings were returned.
And out of 1200 random drug tests only 22 positive reading were returned. The cost of these drug and alcohol tests to the taxpayers is $400,000 a year.
The inquiry found a long list of shortcomings related to the Office of Transport Safety Investigations being a division of state rail regulator, the Independent Transport Safety and Reliability Regulator.
Under this arrangement the chief investigator of Safety Investigations is appointed by and can be removed by the chairman of the advisory board of the Reliability Regulator. This, said Mr McInerny, "creates at least the perception that the advisory board may influence the contents of the reports of the chief investigator". As a result "the advisory board must be abolished".
The inquiry also found: "The culture of RailCorp continues to be focused on on-time running, without adequate and proper consideration being given to safety matters". It pointed that this "culture is misconceived. Emphasis on safety increases the efficiency and punctuality of a railway."
The report also found that although RailCorp pushed a "no blame" line when safety incidents occurred, in practice this was not followed with workers immediately being taken off duty for even minor incidents and sent for psychological testing.
There has been "a breakdown in trust" between management and staff. The report also noted that train drivers were mostly blamed for any disruption to services and that drivers were pressured to breach rules to meet on-time running.
In addition Mr McInerny found:
Emergency response and communications are crippled by delays, lack of coordination and incompatible systems;
RailCorp fails to allow passengers to escape from trains in an emergency;
A failure to keep computer records of documents raising safety issues;
Staff reports of faulty trains have been ignored and discouraged.
Recommendations from the report include:
Abandonment of the passenger containment policy in the event of an accident;
All new rail cars to have roof access for emergency services;
Managers to a certain level to receive compulsory safety training;
Management must move away from the a "blame-the-workers" approach.