A damning 435-page report released this month into last year’s Waterfall train disaster has blamed the management of former New South Wales (NSW) State Rail for the accident, the worst in 26 years.

Seven people, including the 53-year-old train driver Herman Zeides, were killed and about 42 passengers suffered injuries on January 31, 2003, when the Tangara passenger train hit an embankment. The train suddenly increased speed and jumped the tracks after leaving Waterfall railway station, about 40 kilometres south of Sydney.

The inquiry, which was headed by Justice Peter McInerney, concluded that the crash was the failure of the train’s “deadman brake” to operate after the driver suffered a heart attack. While the NSW Labor government previously attempted to blame the deceased driver for the disaster, the report exonerated Zeides, declaring that he had “not contributed to the accident through recklessness or carelessness”.

It also found that the train’s guard, William Van Kessel, whose role over past months has been the subject of considerable adverse media speculation, was unable to respond adequately during the accident. Van Kessell, the inquiry said, had not been properly trained to cope with emergency situations, was suffering fatigue at the time of the accident because of his rostering, and was unaware of problems with the deadman brake.

Pointing to what it termed “a pervasive lack of safety awareness” and “weak safety culture” at managerial levels, the inquiry revealed that State Rail management had ignored reports made as early as 1988 warning that the deadman brake on Tangara trains may not have been foolproof.

At least three reports by consultants and experts between 1992 and 1996 said that the device, which activates the braking system if the driver fails to keep constant pressure on a floor pedal, was inadequate. They warned that the brake could be overridden by the passive weight of an unconscious man’s leg and recommended the urgent installation of a backup Vigilance Control System, which would require drivers to periodically press a button indicating that they were alert. The advice, however, was not acted on.

The Waterfall inquiry report pointed out that despite these serious warnings “no appropriate testing was carried out”. It declared that State Rail’s “cursory attitude was, and remains, indefensible, given that a critical piece of safety equipment was involved”.

The inquiry also uncovered other safety issues, including the lack of proper emergency training for rail staff, failure to fix reported hazards, rostering that ignored the dangers of fatigue, and an unsatisfactory medical checking system for staff. State rail medical examiners failed to establish that Zeides was suffering from a chronic heart condition. His post mortem revealed that one of the two arteries supplying blood to his heart was 90 percent blocked.

As soon as the report was released NSW state premier Bob Carr called a press conference and denounced rail management, blaming them for the accident. Flanked by current Minister for Transport Michael Costa and Carl Scully, the former transport minister, Carr said that his government would “shake this organisation [the railways] until managers become safety fanatics”.

While claiming that the Labor government took “full responsibility” and would ensure “fair compensation” for crash victims, Carr declared, however, that his ministers were not to blame and defended Scully, who held the public transport portfolio at the time of the disaster.

Carr claimed that numerous safety problems with the Tangara trains, including the faults with the deadman brake, had been kept from Scully and previous transport ministers and rail CEOs. Echoing Carr, Costa said: “I blame management. Management allowed this to happen.”

A few days later Arthur Smith, former deputy chief executive of State Rail, and Ron Bruce, a project manager in the capital works department and head of the Tangara project, were sacked and denied termination payments.

Carr’s denunciations of rail management are a cynical attempt to prevent any connection being made between the Waterfall disaster and the state government’s cost-cutting policies.

One of the first actions taken by the Carr after coming to power in 1996 was to break up the State Rail Authority into three separate stand-alone commercial entities responsible for various aspects of railway operations and management given orders to cut costs. This was in line with big business demands for cuts in public spending and the preparation of profitable sections of public transport for privatisation.

A host of cost cutting measures were undertaken in all three sections—State Rail, Rail Access Corporation and Rail Services Australia. Many of these impacted directly on safety, creating the conditions for major rail disasters. Long-standing problems with crucial infrastructure, such as serious disrepair of scores of rail bridges, were deliberately ignored; maintenance on rail lines and signaling equipment was drastically cut back or outsourced; and many hundreds of staff, essential for the safe running of the rail system, were axed.

While State Rail managers are immediately responsible for the Waterfall disaster, managers of the state-owned service do not operate in a political vacuum. Their actions were guided by government directives to slash costs, or else. Proper safety standards on the other hand inevitably require time and money—investment in adequate staffing, training and up-to-date equipment.

For example, the recommendation to install Vigilance Control Systems in trains was ignored because it would have cost over $33 million, a substantial outlay for sectional heads under government pressure to cut costs. In fact, these devices are only now being installed because of the Waterfall inquiry, years after it was recommended, and will not be completed until March.

Even the fact that Zeides’ heart condition went undetected is related to the government’s rigid financial guidelines and its demands for the maintenance of on-time train schedules. Under these conditions releasing drivers and other key personal for regular medical checks, or of relieving them of duty on full pay until a clean bill of health could be established, would have been out the question.

Drivers with diminished capabilities because of advancing age, poor health—often the result of highly stressful employment conditions—have been required to continue working because of the cost involved in placing them in other jobs on the same wage and the cost of training the needed replacements.

Helen Willoughby, spokesperson from the newly formed RailCorp, highlighted the acute shortage of train drivers on January 16. She revealed that the organisation currently employs only 1,230 drivers who were reaching retirement age at the rate of 10 a month. Willoughby admitted that even if existing train drivers did the maximum amount of overtime allowable, they could not provide a full rail service.

While the state government has announced that new standards for medical examinations would be introduced next month for drivers, guards, signalers, train controllers and other critical rail staff, it is also using the situation to implement cuts to services. RailCorp’s chief executive Vince Graham said that his officers would develop a “hierarchy of cancellations,” including cuts to weekend timetables and “low capacity services”. Costa said he expected these disruptions to continue for more than six or eight months.

Costa has now reintegrated all three corporations into the new entity RailCorp, but the same commercial considerations will continue to dominate. This was made clear last April when he rejected recommendations that the government allocate $1.5 billion emergency funding for rail services, saying that problems could not be fixed by throwing money at them. Just weeks ago Costa confirmed that despite widespread public opposition he was considering a new round of cost cutting measures including the closure of a number of country train services and job layoffs in the next 12 months.

Despite Carr’s denials, his government is fully responsible for the parlous state of the NSW rail system. This was previously highlighted by the train collision at Glenbrook near Sydney in 1999 that claimed seven lives. The inquiry into that disaster, also headed by McInerney, said it was caused by inadequate rail maintenance, equipment breakdowns, poor communications and monitoring systems. It also determined that rail management was pressed to maintain on-time running at the expense of safety.

The Glenbrook inquiry also recommended establishment of a “totally independent” transport safety regulator free of commercial considerations. This was ignored.

Instead, the government announced the establishment of a Transport Safety and Reliability Regulator whose responsibilities included overseeing train reliability and on time running—two competing and incompatible tasks. In other words, under pressure of tighter budgetary constraints and reduced manning levels, the same so-called regulatory body was given an impossible task—to improve safety while boosting productivity.

No one should be fooled that the Carr government’s decision to sacrifice a couple of managers will produce any change in the policies that produced the Waterfall rail crash. The government’s ongoing attempts to find scapegoats are a sure sign that its cost cutting measures will continue, regardless of the social consequences. Inevitably, further accidents will occur with the potential for even greater losses of life.