ASSESSMENT 1 -CRITICAL REVIEW: CASE STUDY 1

Kerang Train Accident

Safety and Risk Management

MAJEED AHMAD KHAWAJA
Roll num 19311728

School of Computing, Engineering and Mathematics

Western Sydney University
 ABSTRACT
This study focuses on making the concepts of the safety protocols for a system. To achieve
the goal, it is assigned to select a train crash in history, collect the facts and figures about
it, analyze the data and find out how safety breached and the accident occur.
For this purpose, the Kerang Train accident, which occurred on 05 June 2007 in Victoria
Australia, is selected and the data about it is collected from government department
reports, news headlines and newspapers. The data is analyzed to find of the root cause
of the accident, relative safety protocols of the relevant system are studied and these
protocols are connected with the root causes to find out the safety breaches, safety flaws
and the responsible ones. Finally, the report is concluded and the changes made after the
accident are discussed.
Table of Contents
Introduction:................................................................................................................................................. 3
Australian Railway Safety management: .................................................................................................... 3
Kerang Train Accident: ................................................................................................................................. 3
The Accident: ............................................................................................................................................ 4
Driver and Road Vehicle:.......................................................................................................................... 5
The infrastructure of crossing and investigational facts:........................................................................ 5
Possible safety Breaches and flaws in the system: ..................................................................................... 6
Conclusions: .................................................................................................................................................. 7
Improvements: ............................................................................................................................................. 7
References: ................................................................................................................................................... 9
 Introduction
Safety is the term that explains a state in which the possibility of the uncertainty, accident
or harm is controlled to a minimum accepted level. Safety policies are the rules which are
made to be followed while doing a process or following a procedure. Safety policies do
cause changes and have a great effect on procedures but the safety protocols are never
neglected while making procedures so that harm could be minimized.
Safety management is the structure of the policies, protocols, procedures and rules that
are to be followed by the organization and the contributors of the system. Worldwide,
the standards and Standard Operating Procedures are made to apply the safety
management system. Standards like ISO, JIS etc are made on the basis of safety protocols.

Australian Railway Safety management:

The office of National Rail Safety Regulatory (ONRSR) look after the relevant safety affairs
of the Australian railway system. They are responsible for the improvement of the safety
of rail for the community, enforcement of the regulatory compliance, share and decrease
the burden of regularities on the rail market and industry, provision of the flawless
national safety regulation.(ONRSR safety 2006)
The council of Australian Governments which have established ONRSR administrates the
rail safety law that is nationally consistent and called Rail Safety National Law. The law
was first enacted in South Australia and all the territories and states passes the replica of
the same law and ONRSR is responsible for the rail safety and all the regarding regulations
in the state or territory(ONRSR law, 2006)

Kerang Train Accident:

Road and rail transport is particularly important in Australia because people live among
long distances. They travel and transport things for living. There have been many level
crossing incidents which arose as a big risk for the safety rail transport industry(safety
bureau, 2008). The incident we are studying here is from Victoria and there are total 1872
road – rail crossings in Victoria only (Road safety committee, 2008) . There have been 192
collisions between trains and road vehicles at the rail road crossings from 2002 to 2012 in
Victoria. Estimated eight percent from these incidents involved deaths and causalities
(Transport Council 2003)
The Accident:
On 5th June, 2007 a collision occurred between a load transporting semi-trailer and a v-
line passenger train at Murray valley highway in North Victoria Australia. The railway line
was swan hill railway line and incident occurred approximately ten kilometers north of
the kerengan town. The train was departed from swan hill highway station and was
destined to Melbourne. The train was pulling three carriages and a locomotive.

Fig; the location map of incident.

The trailer hit the second of the three carriages which cause the detachment of the third
carriage from the train which was derailed later. The strike was hard enough to destroy
and open the whole side of the carriage. There were 39 people onboard according to the
records. Total twenty-five people received injuries from them and eleven of them were
fetal (safety investigations, 2008).
 Fig; the locomotive being hit by the truck. (safety investigations, 2008).

Fig: Truck after accident (safety investigations, 2008).

The truck was around 40 tones loaded, and travelling at 100km/hr (news.com.au, 2009).
There were alarms and traffic lights on the crossing and still in alarming position when
the rescue teams arrived but there were no broom gates installed (ABC news, 2007).
Driver and Road Vehicle:
Chris scholl was the fully licensed driver of the commercial heavy vehicles with 31 years
of experience. He was deaf from one ear and right eye required him to have glasses. The
driver saw the light structure but he did not saw that red light was flashing neither he saw
the train approaching nor he heard the sirens. His police statement was “I didn’t expect
the train because I looked at the lights and they were not flashing so I didn’t expect the
train coming”(coroners court 2013). He saw the train coming from behind the trees and
car waiting on the other side of crossing when he was 90metres away from the crossing.
Driver applied the brakes but it was too late as trailer already hit the carriage after being
dragged due to momentum. This size of the truck require atleast 138 meters to stop at
this speed(hart, 2011). The truck was heavily damaged but driver survived and only had a
head and a shoulder injury.
The infrastructure of crossing and investigational facts:
The road was 3.7 meter wide with the speed limit of 100kph and the current speed of
the truck was in accordance with the rules. There were two types of warnings present
there on the crossing.
 The passive components included the speed limit signs, stop warning signs,
rumble strips and warning signs.
  Active components included the flashing red lights and bells those were too be
activated by the approaching train.
Train was displaying the head and ditch lights and the driver activated the horn as per
protocol and again activated it for seven seconds when he saw the truck coming, which
clearly Mr school missed to hear. The train horn was continuously sounding from the
point when the train was 140m away from the crossing. He was two seconds or 40 meters
away from the distance where he could have controlled the speed.

Fig; description of the tracks of accident location(safety investigations, 2008).

Warning time is the time by which all the alarming devices should be activated before the
entrance of the rail in the crossing region. It must be enough to let the currently crossing
vehicles to evacuate the crossing. According to the Australian standards AS 1742.7-2007
this time is 20seconds. In Victoria, it is 20 to 25 seconds. The safetran Event analyzer
recorder (SEAR 11) recorded the time of the activation of the warning circuit. It recorded
the time of 25.4 seconds and total speed of 96.3kmh of the train.

Possible safety Breaches and flaws in the system:

The infrastructural failure could be following at the crossing.
 The speed limit was 100kph which is too much for loaded trucks to stop.
 The right hand curved preceding the level crossing only allows the time of 0.5
seconds to respond the flashing warning light and other warning signs.
 The lights were focused on the drivers sitting at car elevation level but from the
height of this truck, it would never have been in the focus.
 The installed red filtered lights were based on incandescent bulbs which are
outdated and they should have been replaced with LEDs which are more
prominent.
 Broom gates were not installed which were major cause of the accident.
  According to the Victoria Government Gazette of 28Oct1999, Rule 123, the driver
of the vehicle on road must stop and should not enter the crossing when the
warnings ie flashing light and alarm bells are ringing. The driver of the truck break
this rule and accident occurred.

Conclusions:
There could be three possible scenarios, which could have caused the accident.

 The driver thought of continuing the speed and pass before or after the train
after observing the signal warnings.
 The driver observed the warning signals and took too much time for making any
decision and making an appropriate reaction.
 The driver didn’t see the activated warning and train coming until there was no
time left to understand what is happening and how should he react.
In the first scenario, this requires a high level of risk taking and negligence to do this. There
would be a greater error in the estimation for such experienced person. In case of second
scenario, is can be said that the driver was not fully aware of what is coming next after
observing the passive devices and when he observe the active signs, he couldn’t react
properly. In last case, which is true according to the driver. This requires a considerable
lack of focus and concentration while driving crossing the level crossing.
The investigations say that lights were flashing when the truck was 700m away from the
crossing. The lights were clearly visible to the driver from 300 meters and a warning sign,
which was clearly visible, was 260 m away from the crossing. These were enough to warn
the driver to stop and he had enough time to control the brakes(safety investigations,
2008).
Finally it can be concluded that the truck driver didn’t responded in appropriate manner
and time and major safety missing at the site was the absence of broom gates.

Improvements:
Following improvements are made for improvement of the safety at the site after crash:
 Boom gates are installed which were major safety breach at the site.
 Flashing LED lights were installed.
 Rumble strips, Electronic Bells, road markings and warning signs according to the
Australian Standard AS1207.7-2007 are now included in the infrastructure.
 The speed limit is reduced to the 80kph.
Following improvements are recommended to decrease the hazard and risk
 The active warning signs should be at the distance where passive signals are
installed to provide more time and to catch more attention.
 Road speed breakers should be installed.
 The main light of the train should also flash when the warning horn is activated.
References:
Australian transport safety bureau, ‘Rail safety investigation; key lesson learnt’ rail
safety bulletin RR-2008-008, july 2008.
Road safety committee, Parliament of Victoria, ‘Inquiry into improving safety level
crossings’ Dec 2008.
Australian Transport Council, National Railway Level crossing behavioural strategy,
August 2003.
news.com.au, "Truckie 'speed error' behind 11 Kerang deaths". 26 May 2009.
Retrieved 21 January 2011.
ABC News, "Three still missing after Vic train smash". 6 June 2007. Retrieved 5
January 2018.
Coroners Court of Victoria.Scholl trial transcript, Coronial investigation of 26 Rail
crossing deaths in Victoria Australia. October 2013. Retrieved 5 January 2018
Peter hart, “Kerang Train crash Inquest Braking capability of the truck”, 12 May 2011.
Transport and Marine Safety Investigations, Level Crossing Collision V/Line Passenger
Train and a Truck Near Kerang, Victoria. Chief Investigator, 15 February 2008.
Retrieved 5 January 2018.
(ONRSR’s statement on intent available at https://www.onrsr.com.au/about-
onrsr/statement-of-intent)
(ONRSR’s Rail Safety Law available athttps://www.onrsr.com.au/about-onrsr/legislation)