Special Commission of Inquiry Into the Glenbrook Rail Accident Final Report April 2001 The Honourable Peter Aloysius McInerney Special Commission of Inquiry into the Glenbrook Rail Accident 11 April 2001 Her Excellency Professor Marie Bashir A.O., Governor of the State of New South Wales Office of the Governor Macquarie Street SYDNEY NSW 2000 Your Excellency, I was appointed by Letters Patent issued on 9 December 1999, and varied by Letters Patent issued on 14 April 2000, 23 August 2000, 13 December 2000 and 27 February 2001, under the authority of the Special Commissions of Inquiry Act 1983 to inquire into and report to Your Excellency on the following matters: 1. The causes of the railway accident at Glenbrook on 2 December 1999 and the factors which contributed to it; 2. The adequacy of risk management procedures applicable to the circumstances of the railway accident; and 3. Any safety improvements to rail operations (including any relevant structural changes) which the Commissioner considers necessary as a result of his findings under matters 1 and 2 and as a result of consideration of the reports of the rail safety investigations and any coronial report into railway accidents at: • Redfern on 6 April 2000 • Hornsby on 9 July 1999 and 11 January 2000 • Olympic Park on 2 September 1999 and 14 November 1999 • Waverton on 20 December 1999 • Kerrabee on 18 August 1998 and • Bell on 15 October 1998. By the said Letters Patent it was declared that sections 22, 23 and 24 shall apply to and in respect of the Special Commission the subject of Your Excellency’s Letters Patent. Special Commission of Inquiry into the Glenbrook Rail Accident 2 The Letters Patent, as so varied, stated “AND OUR further will and pleasure is that you do deliver any interim reports and your final report in writing of the results of your inquiry as expeditiously as possible, but in any case on or before 11 April 2001, to the office of Our Governor in Sydney”. I present my final report for Your Excellency’s consideration. Yours faithfully, The Honourable Mr Acting Justice Peter Aloysius McInerney TABLE OF CONTENTS Chapter 1 Introduction 1 Chapter 2 The Two Interim Reports 8 Chapter 3 Management of Rail Safety 18 Chapter 4 Safety Culture 39 Chapter 5 The Adequacy of Risk Management at Glenbrook 54 Chapter 6 The Eight Other Accidents 78 Chapter 7 Specific Rail Safety Issues 115 Chapter 8 The Structure of Rail Safety Management 160 Chapter 9 Recommendations 179 1. Introduction The Glenbrook rail accident occurred on 2 December 1999 at 8:22 am. Seven passengers in the front compartment of the first carriage of the inter urban train were killed and 51 passengers were transported to hospital with injuries. Many other passengers sustained injuries which did not require their immediate hospitalisation but which have caused significant physical or mental impairment to them. On the same day I was flown by helicopter to the scene of the accident where I viewed the two trains in the collision position. The Glenbrook rail accident was the most serious rail accident in New South Wales since 6 May 1990 when an inter urban train collided with a special steam train on the Cowan embankment near the Hawkesbury River north of Sydney in which six persons were killed and 100 passengers injured. The most serious rail accident prior to that occurred on 18 January 1977 at Granville when an eight car passenger train derailed and collided with the Bold Street bridge, causing the bridge to fall on the third and fourth carriages of that train resulting in the deaths of 83 passengers with injuries to a further 213 passengers. The urgency with which the inquiry into the Glenbrook rail accident needed to be commenced was increased by the fact that in the period of approximately two years before the accident there had been a number of rail accidents involving derailments of trains or the deaths of trackside workers and Sydney had been chosen as the venue for the 2000 Olympic Games. The safety and reliability of the rail network was critical to the success of the Olympic Games. The Glenbrook rail accident was a matter of intense public interest for these reasons and because the CityRail network carried approximately 900,000 passengers per week day, each of whom had an interest in the safety and reliability of the rail network. On 9 December 1999 Letters Patent were issued appointing me as a Commissioner under the Special Commissions of Inquiry Act 1983 and on 10 December 1999, by Instrument of Appointment under the hand of the Attorney General, Christopher Thomas Barry QC and David Cowan were appointed as Counsel Assisting. For the reasons stated above it was necessary to proceed with the inquiry with the utmost expedition. This involved obtaining a suitable hearing room and equipping it with facilities to accommodate the large number of parties who would be seeking leave to appear and with the technological equipment to produce and retain electronic copies of real time and historical transcript, the exhibits and documentary materials. I wish again to acknowledge the assistance of the Chief Justice who made Court 10A available and the work done by Ms Janine Taggart of the Supreme Court staff in providing that court room with the equipment and facilities necessary for it to be operated as an information technology court room able to hold electronic copies of the large volume of exhibits tendered in evidence and the transcript. I also wish to acknowledge the assistance of Mr William Grant, Deputy Director General of the Attorney General’s Department who willingly undertook the co-ordination and organisation of the 1 administrative and funding arrangements that needed to be put in place for the Special Commission of Inquiry. Because of the public interest in the inquiry the media were encouraged to attend and a room with its own television monitor and live transmission from the hearing room was established for the assistance of media representatives attending the hearings. I wish to acknowledge the assistance in liaison with media representatives that was provided by the Supreme Court public information officer, Ms Kimberley Ashbee. It was necessary not only for a hearing room to be obtained and equipped but for the Special Commission of Inquiry to establish an office and a staff and for me to be provided with personal staff to enable the work of the inquiry to commence. Following directions hearings on 22 December 1999 and 27 January 2000 I directed that the hearings would commence on 14 February 2000, a little over eight weeks after the accident. For reasons of strict economy it was decided not to retain the services of a Secretary to the inquiry. The difficult and burdensome administrative tasks of preparing for the hearings and obtaining evidence were carried out by the solicitor instructing Counsel Assisting, Ms Christine Johnpulle, Senior Solicitor, from the Crown Solicitor’s Office, who was seconded to the Special Commission of Inquiry with assistance and advice from Counsel Assisting. This frequently involved Ms Johnpulle, particularly when the office of the Special Commission of Inquiry was being established, in working for extremely long hours, for days at a time, including weekends, and often in her own time. In the first part of the inquiry, which dealt only with the first matter referred to in the Letters Patent as varied, namely the causes of the Glenbrook accident and the factors which contributed to it, 96 witnesses gave evidence and 92 exhibits were tendered. Except for two days upon which inspections were conducted, and one day allowed for counsel for the parties to prepare oral submissions, the Special Commission of Inquiry sat continuously from 14 February to 19 April 2000. The public interest in the inquiry and the public concern about the safety of the rail network led to an interim report dealing with the first matter referred to in the Letters Patent. That interim report was delivered on 6 June 2000 to the Governor. On 8 June 2000, directions were given for the future conduct of the inquiry. In order to formally consider the adequacy of the risk management procedures in force at the time of the Glenbrook rail accident, I directed each of the rail entities and the Director General of the Department of Transport to prepare and deliver detailed reports relating to the procedures that were in place and their respective assessments of the adequacy of those procedures. I also invited each of the rail entities to include proposals that each had for the improvement of the safety of rail operations, and any other material which each thought may assist in relation to the second and third matters that I was required to inquire into and report on by the Letters Patent as varied. At the request of the rail entities I subsequently extended the time for delivery of those reports, and eventually each of those parties complied with the direction for detailed reports dealing with those matters. The 2 reports by the rail entities were each received on 10 July 2000. They were responded to by the Director General of the Department of Transport on 11 August 2000. Subsequently, I received a letter, dated 16 August 2000, from the Premier, requesting a second interim report “by 31 October 2000 which would outline any important measures that may require legislation”. No public hearings were held between 1 September and 9 October 2000, at the request of the rail entities who were supported by the Department of Transport, because of the 2000 Olympic Games and the demands they made on their respective resources.