https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf

Skimming through it rather confirms what I suspected based on the
information available earlier - the procedures in use to manage the
signal outage were inherently unsafe.

I'm left aghast by the fact that train authorities did not have to be
read back. The people who made that decision have no understanding of
human factors risks, and have no business being anywhere near the sharp
end of train operations.

We don't know, and never will know, exactly why the driver did not slow
the train to enter the loop, but any system that relies on a single
person to know of the unusual need to slow, and to remember to do so,
was just an accident waiting to happen.

Sylvia.

On Wed, 9 Aug 2023 23:36:08 +1000, Sylvia Else <sylvia@email.invalid>
wrote:

>https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf
>
>Skimming through it rather confirms what I suspected based on the
>information available earlier - the procedures in use to manage the
>signal outage were inherently unsafe.
>
>I'm left aghast by the fact that train authorities did not have to be
>read back. The people who made that decision have no understanding of
>human factors risks, and have no business being anywhere near the sharp
>end of train operations.
>
>We don't know, and never will know, exactly why the driver did not slow
>the train to enter the loop, but any system that relies on a single
>person to know of the unusual need to slow, and to remember to do so,
>was just an accident waiting to happen.
>
>Sylvia.

Until money, a lot of money is spent on tracks keeping train speeds
below that of a bicycle and lower more of this will come
--
Petzl
Good lawyers know the law
Great lawyers know the judge

Petzl <petzlx@gmail.com> wrote:
> On Wed, 9 Aug 2023 23:36:08 +1000, Sylvia Else <sylvia@email.invalid>
> wrote:
>
>>https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf
>>
>>Skimming through it rather confirms what I suspected based on the
>>information available earlier - the procedures in use to manage the
>>signal outage were inherently unsafe.
>>
>>I'm left aghast by the fact that train authorities did not have to be
>>read back. The people who made that decision have no understanding of
>>human factors risks, and have no business being anywhere near the sharp
>>end of train operations.
>>
>>We don't know, and never will know, exactly why the driver did not slow
>>the train to enter the loop, but any system that relies on a single
>>person to know of the unusual need to slow, and to remember to do so,
>>was just an accident waiting to happen.
>
> Until money, a lot of money is spent on tracks keeping train speeds
> below that of a bicycle and lower more of this will come

You presumably mean "above", not "below". But actually this talk in
the media about the need for technology upgrades overlooks the fact
that this was primarily caused by, as Sylvia stated, a procedural
issue. Stupidly implemented technology is no more safe than
stupidly implemented low-tech solutions. Saying better technology
will fix everything is just the typical line of governments
throwing money at a problem instead of facing the awkward issue of
people in authority actually being at fault.

--
__ __
#_ < |\| |< _#

More technology wouldn't have prevented this - they were running in
degraded mode anyway due to other work in progress. Normally there WOULD
have been warning to the driver that they were taking the loop (oi -
that signal isn't showing what I expect!)

What needs to be examined is the processes and check-n-balances in that
process when running 'degraded'.

On 11 Aug 2023 08:37:38 +1000, not@telling.you.invalid (Computer Nerd
Kev) wrote:

>Petzl <petzlx@gmail.com> wrote:
>> On Wed, 9 Aug 2023 23:36:08 +1000, Sylvia Else <sylvia@email.invalid>
>> wrote:
>>
>>>https://www.atsb.gov.au/sites/default/files/2023-08/RO-2020-002%20Final.pdf
>>>
>>>Skimming through it rather confirms what I suspected based on the
>>>information available earlier - the procedures in use to manage the
>>>signal outage were inherently unsafe.
>>>
>>>I'm left aghast by the fact that train authorities did not have to be
>>>read back. The people who made that decision have no understanding of
>>>human factors risks, and have no business being anywhere near the sharp
>>>end of train operations.
>>>
>>>We don't know, and never will know, exactly why the driver did not slow
>>>the train to enter the loop, but any system that relies on a single
>>>person to know of the unusual need to slow, and to remember to do so,
>>>was just an accident waiting to happen.
>>
>> Until money, a lot of money is spent on tracks keeping train speeds
>> below that of a bicycle and lower more of this will come
>
>You presumably mean "above", not "below".
>
Sorry correct, no point in faster trains if tracks can't support
higher speeds
>
>But actually this talk in
>the media about the need for technology upgrades overlooks the fact
>that this was primarily caused by, as Sylvia stated, a procedural
>issue. Stupidly implemented technology is no more safe than
>stupidly implemented low-tech solutions. Saying better technology
>will fix everything is just the typical line of governments
>throwing money at a problem instead of facing the awkward issue of
>people in authority actually being at fault.
>
The Fast rail train between Newcastle and Sydney has been ready to go
for years, just stopped by trade Union leader (RTBU).
>
--
Petzl
Good lawyers know the law
Great lawyers know the judge

On Sat, 12 Aug 2023 09:04:20 +1000, Matthew Geier
<matthew@sleeper.apana.org.au> wrote:

>More technology wouldn't have prevented this - they were running in
>degraded mode anyway due to other work in progress. Normally there WOULD
>have been warning to the driver that they were taking the loop (oi -
>that signal isn't showing what I expect!)
>
>What needs to be examined is the processes and check-n-balances in that
>process when running 'degraded'.
>
? The speed allowed was lower than that of a bike
The PDF is 121 pages this is 5 pages dow
Executive summary
What happened
On 3 February 2020, a fire in a signalling equipment hut at Wallan in
Victoria resulted in damage to the signalling system on the standard
gauge rail network operated by the Australian Rail Track Corporation
(ARTC). Repair of the signalling system would take several weeks and
ARTC commenced managing rail traffic over a 24 km section between
Kilmore East and Donnybrook using administrative systems. The section
was predominantly a single bi-directional track which included a
crossing loop at Wallan.

snip and then

The investigation found that train ST23 derailed due to its speed
exceeding the infrastructure design speed by a significant margin. The
train entered the turnout to Wallan Loop travelling at a speed of
between 114 and 127 km/h following an emergency brake application a
short distance before the turnout. The maximum permitted operational
speed for the turnout was 15 km/h and the train could not negotiate
the turnout at its higher speed.
--
Petzl
Good lawyers know the law
Great lawyers know the judge