The Glenbrook rail accident

In 1999 near Glenbrook west of Sydney, an interurban train collided with the rear of an interstate tourist train, the Indian Pacific. Both were travelling towards Sydney on the same railway line, and were passing through hilly terrain near the base of the Blue Mountains. The immediate cause of the accident was a fault in the automatic signalling equipment resulting in poor control of train movements through the area. Protocols for handling such situations in 1999 were like this. When things were operating normally, a red signal indicated that there was another train up ahead and that the driver should wait until the green light appeared. When a signal failed, the conduct of drivers and signallers was governed by a regulation called safeworking unit 245. Essentially, signallers were to determine whether a signal in the stop position was due to the line ahead being occupied by a train, or a signal failure. In situations of the latter kind, train drivers were permitted to move along the "line ahead" at "extreme caution" on the verbal advice of the signaller.

Prior to this particular accident two adjacent signals about one-and-a-half kilometres apart went into the red or stop positions due to a blown fuse. Unfortunately, the signaller was aware of only the first signal being in the red position. As each driver approached this signal he phoned the signaller for advice. There was no signal board or other equipment that would allow the signaller to see this part of the track so he assumed that the signal was faulty as no other trains had passed through recently. With his authority both trains, which were travelling several minutes apart, passed through. When the leading train, the Indian Pacific arrived at the second red signal it stopped again. The driver, Mr Willoughby, again tried to contact the signaller for instructions. Was this second red signal also due to a fault, or was there actually another train up ahead? Under railway regulations, Willoughby was not permitted to use his Countrylink phone on that part of the track, so he was obliged to leave his cabin and use the signal telephone by the tracks. Telephones are old technology and require the press of a button (bell call) and the cranking of a handle to contact the signaller. Willoughby tried to use it, but received no reply. He assumed that the device was faulty as the call button was missing. In fact, the signaller was momentarily distracted and did not hear the bell. Willoughby next reboarded the train and moved off very slowly, according to his interpretation of Safeworking 245. He had already lost seven minutes waiting at the first signal, and a few more at the second. In the meantime, the interurban train following behind proceeded on its journey at a much faster pace, unaware of the Indian Pacific up ahead. Shortly after rounding a long curve in the track, it ploughed into the back of the leading train. Seven passengers in the front carriage of the interurban train were killed instantly and others were seriously injured, but the driver Mr Sinnett was able to flee the driver's compartment in time.

A combination of factors was at work here. The technology was in serious need of upgrading, and some of the equipment was faulty. However, the crucial ingredients were a failure of management and the organisation to provide clear, unambiguous procedures for train drivers to follow, and flawed assumptions on the part of the drivers and the signaller as to what was happening on the track. Safeworking unit 245 had been in use for over 30 years, although the terminology was confusing and drivers adopted different practices in relation to the speeds they travelled when it was applied. Interpretations of "extreme caution" and the length of track meant by the "line ahead" varied from driver to driver. There was also a suggestion at the inquiry that Sinnett may have been influenced by frequent reminders to reduce timetable delays that were endemic to the rail system - he reached speeds of up to 50 kph as he rounded the final bend in the track. The inquiry also determined that the casual and colloquial tone used in the telephone conversations between the drivers and the signaller distracted attention from important information being conveyed about other trains in the vicinity, particularly to Mulholland. In Sinnett's case, this apparently contributed to his belief that the track ahead was clear and gave him a false sense of security that contributed to the accident. For his part, the signaller did not know that the Indian Pacific was still on that particular part of the track, or somehow overlooked the fact that the Indian Pacific was required to proceed with "extreme caution" and that this might place it in the path of a train closing from behind. He told the inquiry that he "was thrown back on his prior experience" which told him that signals only failed one at a time, and that an interpretation of the current situation would indicate that the track in front of the interurban was clear.

Underline and then describe each cause for the disaster that you can find.

You are in the leadership team; you want to devote most of your resources to minimizing the most significant cause. Now rank the categories of cause (structure, HR, Political and Symbolic/cultural.) 1-4

List the most important causes

Cause category+--	Moura Mine Disaster	Gretly Colliary Disaster	Glenbrook Rail Diaster
Structure	1
HR	2
Politics	3
Symbolic/cultural	4

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