Executive summary
On Friday 22 September 2000, at about 2338, express freight Train 521 derailed when travelling too fast for the first curve encountered descending the 1 in 35 down grade on the Westmere bank. The 2 locomotives were severely damaged when they overturned following the derailment. The locomotive engineer received only minor injuries.
The reason for the excessive speed was the locomotive engineer’s loss of awareness during a microsleep.
Safety issues identified included the control of locomotive engineer hours of duty, fatigue management and the ability of the vigilance system to overcome a short-term attention deficit in sufficient time to allow effective corrective action to be taken.
Related Recommendations
revise the operation of the vigilance device system to provide a better defence against short duration microsleeps.
put in place control measures to ensure: • Mini Rosters are controlled within separate defined criteria compatible with the principles used in compiling base rosters • The principles of rostering are applied to the overlapping weeks of consecutive rostered fortnights • defined criteria are met before offering extra shifts to LEs • actual hours are monitored and immediate corrective action taken when late running or other factors increase rostered shifts to defined unacceptable levels.
implement Alertness Management courses to reach at least 90% of LEs by the end of 2001 and 100% by the end of 2002