Ian Sinclair Marks - Independent Railway Consultant - Lessons learned from derailments - a metallurgists experience

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Ian Sinclair Marks delivered the presentation at 2014 Major Rail Occurrence Forum (Derailments).

The RISSB Major Rail Occurrence Forum (Derailments) has been designed to build on and continue the analysis of major occurrence reports and to seek Industry learning from them. By reviewing major occurrence reports, Rail Organisations have the opportunity to learn from the lessons without having to suffer the same occurrence.

For more information about the event, please visit: http://www.informa.com.au/derailments14

Published in: Business, Health & Medicine
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Ian Sinclair Marks - Independent Railway Consultant - Lessons learned from derailments - a metallurgists experience

  1. 1. Lessons learned from derailments - a metallurgists experience Ian S Marks 30th April 2014 Sydney NSW
  2. 2. MAJOR RAILWAYMAJOR RAILWAY OCCURENCEOCCURENCE Fatal accidentFatal accident CollisionCollision DerailmentDerailment OCCURENCEOCCURENCE INVESTIGATIONINVESTIGATION Collection of evidenceCollection of evidence PreliminaryPreliminary investigationinvestigation Determination ofDetermination of PREVENTIONPREVENTION Implementation ofImplementation of recommendationsrecommendations Effect safety mgmt.Effect safety mgmt. system improvementssystem improvements Verify improvementsVerify improvements are implementedare implemented MAJOR OCCURENCEMAJOR OCCURENCE INVESTIGATIONINVESTIGATION PROCESSPROCESS OCCURENCEOCCURENCE INVESTIGATIONINVESTIGATION REPORTREPORT FindingsFindings ConclusionsConclusions RecommendationsRecommendations Determination ofDetermination of primaryprimary causecauseare implementedare implemented
  3. 3. Importance of evidence Collection of all evidence is fundamental to determining the primary cause of the occurrence and in preventing a similar occurrence from happening again.
  4. 4. TRAIN 2 CENTRE LOCOS 3 & 4 TRAIN 1 WAGONS 42-50 TRAIN 1 CENTRE LOCO 3 TRAIN 1 WAGON 52 PoD??
  5. 5. TRAIN 1 CENTRE LOCOS 3 & 4 TRAIN 2 WAGON 50 TRAIN 1 WAGON 51
  6. 6. TRAIN 1 WAGON 47 TRAIN 1 WAGON 42 TRAIN 1 WAGON 38
  7. 7. EVIDENCE FOUND 5 WEEKS AFTER THE DERAILMENT...!
  8. 8. Derailment investigation outcome The investigation did not find the primary cause of the derailment due to; • the scale of the task to collect the evidence. • the late involvement of investigative specialists. • the lack of direction in prioritising the collection of evidence. • the disorganised collection of evidence and loss of evidence.• the disorganised collection of evidence and loss of evidence. • no quarantine protocols in place for collected evidence.
  9. 9. WAGON 3
  10. 10. WAGON 15 WAGON 18
  11. 11. WAGON 16 WAGON 18 WAGON 22 & PoD
  12. 12. WAGON 18 WAGON 22 WAGON 16
  13. 13. WAGON 22 POINT OF DERAILMENT
  14. 14. Importance of evidence RAIL BREAK SEQUENCE 4TH 3RD 2ND 1ST 5TH
  15. 15. Importance of evidence 1ST BREAK CONTACT ZONE
  16. 16. Importance of evidence CONTACT MARKS CONTACT MARKS
  17. 17. Evidence of rail break – Wagon 8 wheel sets
  18. 18. Derailment investigation outcome The primary cause of the derailment was found because the investigators; • prioritised the preservation of evidence. • quarantined the collected evidence. • investigative specialists were on site in time. • the collection of all evidence gave the investigation direction.• the collection of all evidence gave the investigation direction.
  19. 19. Collection of Evidence The organised collection of evidence provides the investigation with; • direction, • effective and efficient decision making, • the ability to collect key pieces of evidence for subsequent forensic examination,examination, • the ability to minimise the time investigators are on site, • the ability to reduce the total cost of the investigation and • the ability to determine the primary cause of the occurrence.
  20. 20. Investigation Experience From my experience with rail related occurrence investigations the following aspects of the investigation process need improvement; • notification of the occurrence must be made to the regulator, all stakeholders and the full investigation team - simultaneously. • the investigation team must include the regulator’s representative, investigator/s, investigative specialists and the stakeholder’sinvestigator/s, investigative specialists and the stakeholder’s representative, and all must be on site within 36hrs after notification. • investigative specialists must be independent. • the stakeholder’s representative/s may only be allowed to observe the occurrence. • the collection of evidence must be organised. • the quarantined evidence must be respected.
  21. 21. Prevention of future occurrences The risk of a similar major occurrence happening is reduced significantly when recommended changes have been effected in the safety management system standards. The implementation of any system change is a shared responsibility, of differing jurisdiction, and is the role of:differing jurisdiction, and is the role of: • Regulators, • Administrators, • Investigators, • Practitioners and • everyone!
  22. 22. THANK YOU

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