Presentation: Mark Smallwood, April 2014
The Eight-Year Itch
Derailment investigation
in Victoria 2006-2014
WHY THE ITCH?From Wikipedia
Ø  The seven-year itch is a psychological term
that suggests that happiness in a relationship...
Ø  Frustrated/irritated?
Ø  Getting closer or drifting apart?
Ø  A changing environment in Victoria
The Chief Investigator, Transport Safety
Ø  Position and office established August 2006
Ø  Ian McCallum 2006-2012
Ø  Ch...
Kerang 2007
Tram-to-tram
V/Line Bus Rollover Heathmere 2009
Statendam
Grounding 2006
Port Phillip Heads
Release of reports 2006-2014
Ø  Investigation reports released to the Minister,
with public release on the OCI website
Ø...
Derailment 25% of OCI investigations
Derailment investigated in Victoria
2006-2014 = 34 (OCI 26, ATSB 8)
Sandringham
2011
Sliding of suburban trains:
Ø  2003, first of Nexas train type delivered in Vic
Ø  2006, heightened concern about brakin...
Warracknabeal 2011
Ø  Heavily corroded rail at unsealed level crossing
Ø  Ultrasonic testing did not identify condition
...
Web wasted
Ø  14mm to 6mm
And Again
A similar track
defect resulted in
another serious
derailment
West Footscray 2011
Ø  Crippled joint, led to passenger train derailment
Ø  Planned corrective action not yet completed
...
Safety
+ cost + reputation
Reflecting on 2006-2014
On industry relationship & response
Ø  Our on-site experience - fantastic cooperation
Ø  Barrier...
On investigators – on OCI
An internal view
Ø  Slow to produce reports
Ø  Limitations on in-house capabilities
Ø  Direct...
Scratch or treat the relationship itch?
Engagement (two way) – reluctance/willingness
TRUST – COMMUNICATION – RESPECT
Reta...
capture
?→ →
Questions
Upcoming SlideShare
Loading in …5
×

Mark Smallwood - Office of Chief Investigator (VIC) - The eight year itch - derailments in Victoria

818 views

Published on

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

  • Be the first to like this

No Downloads
Views
Total views
818
On SlideShare
0
From Embeds
0
Number of Embeds
7
Actions
Shares
0
Downloads
12
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Mark Smallwood - Office of Chief Investigator (VIC) - The eight year itch - derailments in Victoria

  1. 1. Presentation: Mark Smallwood, April 2014 The Eight-Year Itch Derailment investigation in Victoria 2006-2014
  2. 2. WHY THE ITCH?From Wikipedia Ø  The seven-year itch is a psychological term that suggests that happiness in a relationship declines after around year seven. Ø  The phrase originated as a name for irritating and contagious skin complaints …. Ø  The phrase …………. has since expanded to indicate cycles of dissatisfaction. A need to reflect, ….. and take action
  3. 3. Ø  Frustrated/irritated? Ø  Getting closer or drifting apart? Ø  A changing environment in Victoria
  4. 4. The Chief Investigator, Transport Safety Ø  Position and office established August 2006 Ø  Ian McCallum 2006-2012 Ø  Chris McKeown 2012-present The office Ø  CI + 5 investigators + an office administrator Ø  Multi-modal investigators Ø  2006-2014, 95 investigations, about 2/3 rail
  5. 5. Kerang 2007 Tram-to-tram
  6. 6. V/Line Bus Rollover Heathmere 2009
  7. 7. Statendam Grounding 2006 Port Phillip Heads
  8. 8. Release of reports 2006-2014 Ø  Investigation reports released to the Minister, with public release on the OCI website Ø  January 2013, a collaboration agreement with ATSB meaning that rail investigations are now performed using the powers of the Transport Safety Investigation Act (Cwlth) and reports released on the ATSB website Ø  All other modes (marine, bus, tram) as previous
  9. 9. Derailment 25% of OCI investigations
  10. 10. Derailment investigated in Victoria 2006-2014 = 34 (OCI 26, ATSB 8)
  11. 11. Sandringham 2011
  12. 12. Sliding of suburban trains: Ø  2003, first of Nexas train type delivered in Vic Ø  2006, heightened concern about braking performance Ø  2006-2007, operator remedial actions partially effective Ø  2008-2011, OCI related investigations Ø  2011, issue finally resolved in Victoria – sanders fitted Ø  2013, Cleveland? Why?
  13. 13. Warracknabeal 2011 Ø  Heavily corroded rail at unsealed level crossing Ø  Ultrasonic testing did not identify condition Ø  Other (visual) inspection regimes inadequate
  14. 14. Web wasted Ø  14mm to 6mm And Again A similar track defect resulted in another serious derailment
  15. 15. West Footscray 2011 Ø  Crippled joint, led to passenger train derailment Ø  Planned corrective action not yet completed Ø  Similar cases of delayed/late action
  16. 16. Safety + cost + reputation
  17. 17. Reflecting on 2006-2014 On industry relationship & response Ø  Our on-site experience - fantastic cooperation Ø  Barriers to cooperation after an event - liability? Ø  Slow to react to broader safety outcomes Ø  Repeated events, organisational inertia Ø  Safety v commercial pressures
  18. 18. On investigators – on OCI An internal view Ø  Slow to produce reports Ø  Limitations on in-house capabilities Ø  Direction of resources to get value An industry perspective on OCI Ø  Too slow Ø  Resolution of differences of opinion? Ø  Other?
  19. 19. Scratch or treat the relationship itch? Engagement (two way) – reluctance/willingness TRUST – COMMUNICATION – RESPECT Retaining independence - guarding against capture Relationship extends to the industry response to investigation findings
  20. 20. capture ?→ → Questions

×