Q&A Session: Expanding the knowledge base of derailment investigations in Australia

Mal Kains, Incident Investigation Manager, Brookfield Rail joins us for an analysis of the evolution of derailment investigations in Australia. He provides an insight into the “busy, interesting and challenging” job of derailment investigations and discusses the main purpose and objectives of rail safety investigations while looking towards the future training and development of rail safety investigators.

Next year will mark the tenth anniversary since the Waterfall rail disaster. Reflecting on your involvement in the investigation and subsequent Commission, have there been changes over the past decade in how derailments are investigated in Australia? If so, what have been the most significant?

Probably the most significant change has been the emergence of ATSB as an independent statutory rail investigation agency, and similar state-based agencies in NSW and Victoria. I’d like to think these organisations provide a level of confidence in the investigation process to deal with issues at all levels.

At an industry level I would say a significant change has been the increasing awareness and adoption of ‘just culture’ principles in the investigation process, whereby errors are treated differently to violations.  Just culture has permitted workers who may have made an unintended error that was a causal factor in an occurrence, to contribute openly to the investigation without fear of disciplinary action. Rail safety workers today are far more willing to talk to investigators than they were ten years ago. Just culture investigations inevitably produce better safety outcomes.

Looking ahead, the National Rail Safety Regulator will commence operations this December.What impact do you see this having on rail investigations?

Around 5000 notifiable occurrences are reported by Australian rail operators each year, with a proportion of these incidents giving rise to investigations. The ATSB have typically investigated around 15 to 20 rail occurrences per year, while the majority of rail safety investigations have been undertaken by accredited operators as part of their obligations under the Rail Safety legislation of their local jurisdiction. In general, these obligations will continue as they are now and apart from the possibility of changes to some notification and reporting processes, I anticipate that little will change for operating companies in terms of investigations.

Coincidentally, but quite separate from the issue of rail safety regulation, the ATSB will become the National Rail Safety Investigator. This means the ATSB’s jurisdiction will no longer be confined to the defined interstate rail network (DIRN) however they will continue to operate as an independent non-regulatory investigation agency. ATSB are increasing their resources in preparation for their increased role, so we can expect to see the ATSB undertaking more investigations in more locations. However rail operators will continue to undertake the bulk of rail safety investigations.

A derailment is a loss of control in what is fundamentally a guidance system. The purpose of a derailment investigation is to come to an understanding of how a failure of the wheel-rail interface occurred, then to use that knowledge to support organisational learning by informing, educating and advising. The primary objective is to achieve a safety outcome; ideally that means preventing a recurrence.

Looking specifically at derailments, what is the main purpose and objectives of rail safety investigations?

A derailment is a loss of control in what is fundamentally a guidance system. The purpose of a derailment investigation is to come to an understanding of how a failure of the wheel-rail interface occurred, then to use that knowledge to support organisational learning by informing, educating and advising. The primary objective is to achieve a safety outcome; ideally that means preventing a recurrence.

There are also moral, ethical, legal and financial imperatives for investigating and preventing derailments.

When you consider that a single derailed bogie may damage several hundred metres of concrete sleeper track before the train comes to a stand, then add recovery costs and lost revenue, it’s easy to see how a simple derailment can result in losses upward of $1million.

When we spoke with RISSB’s Laurie Wilson earlier this year, he commented that the “real significance of derailments is the failure of the system. The benefits from this failure provide the opportunity to learn from it and improve the system to ensure similar occurrences are eliminated or the likelihood of recurrence is reduced”. The number of derailments has been reduced and as we become better at preventing derailments and reducing the numbers even further, how do you see future rail safety investigators acquiring the necessary skills and training to lead rail safety investigations?  

In terms of core investigation skills, the Cooperative Research Centre (CRC) for Rail Innovation has a research project nearing completion that has been developing a framework of competencies to shape the training and development of rail safety investigators. We expect to see a Certificate-level course becoming available soon for new investigators and people such as line managers and engineers who don’t work as full-time investigators. This will be accompanied later by a Diploma-level program, for more experienced investigators who lead as well as participate in an investigation. Both of these courses will be nationally recognised and accredited using AQF Standards.

Investigators will supplement these core investigation skills with elective subjects and by accessing external programs like the RISSB National Derailment Investigation and Analysis Workshop. Beyond this, there is the possibility that an Australian university will offer a Post Graduate Certificate, Diploma or Masters qualification in Investigation as an extension of their forensic science undergraduate degree.

On the specific issue of derailment investigations, as the causes of simple derailments are engineered out, investigators are likely to be involved in more challenging derailment investigations. For example, they may be required to identify how a derailment occurred when the rolling stock and track all appear to be ‘within spec’ and there is no other obvious cause. I also expect that we’ll see simulation techniques and electronic analysis methods playing a greater role in derailment cause analysis. With this in mind, derailment investigators will need to constantly develop their skill set to stay abreast of changes in technology and operating practices, particularly in terms of their understanding of the dynamic relationship between rolling stock and track. So investigator training will need to evolve as new technology comes on-line and fresh research expands our knowledge base.

And finally, in your current role as incident investigation manager with Brookfield Rail in Perth, do you still get the chance to conduct derailment investigations?  

Mainline derailments were trending down from the levels of a decade ago, probably due to a combination of factors which include upgraded infrastructure and improved maintenance and operating practices. We’ve also seen wayside detectors and electronic asset management systems contribute to reducing derailments.

However derailments rates have leveled out over the last few years and I’m seeing investigations becoming more complex and time consuming as simple derailment causes such as broken rails become less common. So the job of derailment investigation remains busy, interesting and challenging.

Mal Kains delivered a detailed overview of the Waterfall accident at the National Derailment Investigations and Analysis Workshop in Canberra in February. He returns to Canberra for the upcoming four day National Derailment Investigations and Analysis Workshop in Canberra on the 24-27 July 2012, where he will provide an introduction to the fundamentals of derailment investigations.

 For more information, visit staging.informa.com.au/derailments