You can’t control the weather

Major Rail Occurrence Forum (Derailments) Sydney – 29-30 April 2014

Tony Simes Manager - Rail

ATSB

•  Accident Investigations –  Aviation –  Marine –  Rail

•  Research –  Aviation / Marine / Rail

Australian Transport Safety Bureau (ATSB)

•  ATSB Rail Investigators –  Perth –  Adelaide –  Canberra –  Brisbane

•  Agreements with –  OTSI (Sydney) –  CITS (Melbourne)

•  ATSB Rail jurisdiction –  NSW –  Vic –  SA –  NT –  Tas –  QLD (DIRN) –  WA (DIRN)

•  Punitive (breaches of law) –  Criminal / Civil –  Regulatory (in some cases)

•  Just Cause (recognises that errors occur) –  Coronial (mostly) –  Internal organisation (preferably)

•  No Blame –  ATSB

Investigation Types

•  Not only ‘What’ happened, but ‘Why’

–  Why did it occur

–  Why did people behave the way they did

–  Why did the environment/system allow it

•  What factors and issues contributed to the accident

•  How can the system be made more error tolerant

•  Risk management

–  Identifying and understanding risk •  Investigations – What and Why

–  Treatment strategies •  Investigations – Lessons learned

–  Monitor and review

•  Response strategies –  How do we respond if something does happen

Major Rail Occurrences - Derailments

•  The state of the atmosphere at a particular place and time as regards heat, cloudiness, dryness, sunshine, wind, rain, etc.: (Oxford Dictionary)

Weather

•  Heat –  Managed by speed

restrictions –  Decision based on

forecasted daily temperatures

•  Wind & Rain ?

•  The most frequent cause of destructive winds and flash flooding is slow-moving thunderstorms

•  A severe thunderstorm is defined by the Bureau of Meteorology as one which produces: –  hail, diameter of 20 mm or more; or –  wind gusts of 90 km/h or greater; or –  flash floods; or –  tornadoes, or any combination of these.

Thunderstorms

•  Strong updrafts of air suspend huge amounts of rain before falling towards the ground –  Downburst of air and water –  Destructive winds radiate outwards at ground level –  Large amounts of water over a small area in a very short time –  Flash flooding when soil absorption, runoff or drainage cannot

adequately disperse intense rainfall –  Water in creeks, drains and natural watercourses can rise very

quickly

Thunderstorms

•  Wind –  Tarcoola, SA (1 Nov 2006) –  Loongana, WA (11 Nov 2008) –  Cadney Park, SA (25 Nov 2010)

•  Rain –  Golden ridge, WA (30 Jan 2009) –  Edith River, NT (27 Dec 2011) –  Roto, NSW (4 Mar 2012)

Example investigations

•  Evidence –  Appeared as though wagons had simply tilted and rolled over

onto their side

–  No evidence of; •  Rolling stock defect •  Track defect, or •  Train handling problem

–  Train driver observations •  Thunderstorms (wind/rain)

–  Bureau of Meteorology

Derailments – Caused by wind ?

•  Analysis –  Wind effects on a vehicle

•  The direction and magnitude of wind force acting on a vehicle is the combined effect of vehicle movement and atmospheric wind

–  Wind tunnel testing –  Wind force calculations –  Similar events

–  The investigation found it possible •  The combined effects of wind load due to the

prevailing thunderstorm conditions, and the wagons’ natural oscillations while travelling, could have been sufficient enough to initiate the overturning of the lightly loaded, double stacked wagons.

Could wind cause a derailment ?

•  Investigation strategies –  Keep an open mind –  Follow the evidence

•  Treatment strategies –  Loading procedures to ensure the combined center-of-mass of

double stacked wagons is as low as possible •  For example, the gross mass of the top tier container(s) must be equal to or

less than the gross mass of the bottom tier container (s)

–  Procedures to ensure containers are only double stacked on specific wagons (for example, low-floor well wagons)

Lessons learned

•  Golden Ridge –  Thunderstorms

•  Limited data or warnings •  Calculations >50yr event

Derailments – Track washaways

•  Edith River –  Cyclone/tropical low

•  >330 mm in 12 hours •  River overtopped rail bridge ( >10.9 m)

–  Bureau of Meteorology (BoM) had issued flood warnings

Derailments – Track washaways

•  Roto –  Thunderstorms

•  >110mm in 24 hours •  ~70mm in 3-4 hours

–  Bureau of Meteorology (BoM) had forecast severe weather and issued flood warnings

Derailments – Track washaways

•  Investigation strategies –  The how and why was relatively straight forward –  Was information available to initiate risk reduction strategies

•  Treatment strategies –  Enhanced procedures associated with severe weather events –  Enhanced systems for accessing information that alerts staff to

severe weather events, including flood risk

Lessons learned

•  Note that in some instances, the next scheduled train was a passenger train.

•  Emergency response –  Injuries to crew or passengers –  Crew and/or passenger comfort

•  Access to site –  Flood waters –  Damages roads –  Road closures –  Access by rail

•  Repair works

Response strategies

•  You may not be able to control the weather, but you can put strategies in place to manage the risk

•  Prevention •  Response •  Investigation •  Review and improve

Summary

Thankyou