Your SlideShare is downloading. ×
Tony Simes - Australian Transport Safety Bureau (ATSB) - Multi organisational occurrence report
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Tony Simes - Australian Transport Safety Bureau (ATSB) - Multi organisational occurrence report

225
views

Published on

Tony Simes delivered the presentation at 2014 Major Rail Occurrence Forum (Derailments). …

Tony Simes 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, Technology

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
225
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
12
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. You can’t control the weather Major Rail Occurrence Forum (Derailments) Sydney – 29-30 April 2014 Tony Simes Manager - Rail ATSB
  • 2. •  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)
  • 3. •  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
  • 4. •  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
  • 5. •  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 ?
  • 6. •  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
  • 7. •  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
  • 8. •  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
  • 9. •  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 ?
  • 10. •  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 ?
  • 11. •  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
  • 12. •  Golden Ridge –  Thunderstorms •  Limited data or warnings •  Calculations >50yr event Derailments – Track washaways
  • 13. •  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
  • 14. •  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
  • 15. •  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
  • 16. •  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
  • 17. •  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
  • 18. Thankyou