The case study is an event, or an occurrence of a situation related to ethical and codes of conduct issues. For instance, a newspaper article about a company’s disposal of toxic waste damaging the environment.
You must research for information related to the topic you have chosen. The research material can be publications, news articles, research papers, books, etc. You must find the outcomes of the event or occurrence and provide judgement and analysis of the resulting outcome. With this judgement and analysis relate it to the relevant industry sector’s professional code of conduct.
Consider two case studies on the selected topic for analysis and comparison. Provide analysis of these two case studies for comparison purpose.
For example, “Hard Disk Disposal when content still exists on it”.
Are there any ethical and professional codes of conduct for such a task?
This report aims to analyse two different train accidents that took place in Australia and in India. The considered case study from Australia is the incident of Waterfall rail incident that took place in the Waterfall, Australia. The second considered case study is the case study of the Jnaneswari Express that occurred in India, which caused the derailment of an express train in the state of West Bengal. A detailed discussion of the incident is provided for both the cases. The cause of the incident in both the case are stated clearly in this report. The problems that led to both the incidents are discussed in this report. The changes that were implemented in both the case scenarios have been stated in this report. Finally, a comparison of both the case studies has been provided in this report. Lastly, this report concludes with an appropriate conclusion for this report.
Train accident is the type of disaster that involves one or more trains. The majority of the train accidents occur due to the result of miscommunication or when two trains meet on the same track or any kind of derailment occurs (Kenny 2015).
Waterfall rail incident
The accident of Waterfall rail was the train related accident that occurred on 31st January 2003, near Waterfall, New South Wales, Australia. The derailment of the train took place that killed seven people including the train driver (Bahr 2014).
The day when the disaster occurred, a Tangara interurban train service, set G7 that came from the Sydney Central Station that departed from the station of Sydney Waterfall station stirring south headed for Port Kembla station through Wollongong (Quigley and Quigley 2013). Approximately, in the morning, the control of the train was lost due to the condition of heart attack faced by the driver. Due to this reason, the train was travelling at 73 mph as it came close to a curve into the tracks over a minor cutting. The rating of the curve is for speed that is no more than 37 mph. The derailment of the train happened, that made the train to overturn and it collided with the rocky walls residing in the cutting in an isolated area that is south of the station. It was discovered several heavy lifting equipment had to be carried by the rescuers for atleast 1.5 km for reaching the site (Sellers 2014). Two carriages were brutally impaired and two of the carriages flipped on their side and were damaged. Including the seven losses, several more passengers suffered injuries.
After rigorous inquiry, it was discovered that the utilisation of the deadman’s brake was not done properly. The solicitor of the guard of the train stated that the guard fell in sleep for about 30 seconds and during this time, the accident happened (Traub and Fraser 2013). The experienced investigator of the human factors accident discovered that the culture of the organisation had the driver determinedly in charge that made the driver psychologically increasingly difficult to act instantly.
Reasons of the accident
The trains of Tangara possesses numerous devices for the concern of vigilance and safety like deadman’s brake for addressing the problems in the situation of the incapacitation of the drivers (O’Flanagan and Seeley 2016). When the pressure is released from the brake by the driver, the train will halt safely. The above considered train was a four-car outer suburban Tangara set, with numbering G7 and it was fitted with an alternating current traction system of Mitsubishi Electric for the evaluation purposes. The leading driving carriage consisted of the driver, the rear driving carriage consisted of the guard and in between these two carriages, and two non-driving motor cars were placed. In this instance, the emergency brake could have been applied by the guard and the major safety mechanism that was in place was deadman’s brake (Buck 2014). Later, it was discovered that the speed of the train at that instant was 73 mph and while it was approaching the curve, the speed was 37 mph (Naweed et al. 2017). Both the driver and the guard did not intervene in this situation and the major reason for the derailment was found to be excess speed. The aspect of the training of the staffs of the train was also later discovered to be a major reason the accident. Inadequate training of the technologies and the methodologies of driving led to the derailment of the train. The train G7 could not be entered for service and eventually, it was scrapped in 2005 because of the damage that was sustained by the train in the accident was beyond repairing (Wong, Hughes and Long 2016).
Systemic causes and neglected technical problems
It was later found during the investigation that several reports were filed regarding the technical problems of the train and it had established a status amongst the branch of mechanical operations, claiming that these problems were for the case. Between the six months prior to the accident, several reports of technical problems were claimed (Haarhoff 2017). Several flaws in the handle of the deadman were discovered and the problems related to the pedal of deadman, which were:
- The pedal of deadman was defeated initially by the dead weight of the overweight and the unconscious state of the driver.
- The enterprise of the deadman’s pedal did not act for operating as thought with the drivers beyond a definite weight.
- The marks found close to the deadman’s pedal indicated that some drivers were trying to wedge a signalling flag that was sized conveniently for defeating the deadman’s pedal for preventing the legs of the drivers from being cramped in the foot well that was purely configured and to provide themselves the freedom to move inside the cabin (Ge 2017).
Various technical problems that were reported for the Tangaras commonly consisted of the failure in brakes and the discovered power surge problems. In the later stages of the investigation of the incident, the technical problems were blamed to be the reason of the accident. Several survivors of the accident claimed that the main reason was the increased acceleration prior the accident occurred. Moreover, an understanding was concluded that the emergency brake must be only utilised due to the acceleration of the train between 3.1 mph and 6.2 mph before the brake was completely applied (Hughes et al. 2015). It was discovered that the trainset of G7 was the sole train in the fleet of Tangara to utilise the induction motors of 3-phase and these systems were not capable of running-away. Moreover, the majority of the braking and the components of the traction system were extensively investigated and examined by the experts from Australia as well as overseas and it was discovered that the systems were performing efficiently (Naweed et al. 2017). The investigation of the damages of the crash were investigated and were discovered not to possess any damage prior to the accident and the problems to cause such an accident. The discovery that was official in the accident claimed that the underdevelopment of the safety culture was also a reason for the accident. The cityrail were also criticised for not implementing proper safety and security issues that resulted in the accident. The code of professional conduct was not properly maintained by the authority and the drivers. The integrity of the drivers can be questioned and the duty that a driver possess for the safe journey for the passengers was also breached (Grover and Pancholi 2014).
Before this derailment, neither the training nor the procedures were properly mandated by the guard for exercising complete control over the train speed by utilising the emergency brake pipe cock. Separately from making the driver the sole operator of the train, the placed emergency brake pipe cock was discovered to not offer the similar degree of control over the automatic brake as a proper brake valve (Hart 2013). The agreement amongst the crews of the train was that the sudden application of emergency brake from the rear could cause a breakaway and some evidence was discovered from the previous accidents that could validate the opinions, however these aspects were not involved in the developed multi-unit design of the Tangara train.
Implementation of changes
All the trains of CityRail have been modified with the implementation of safety failure. Additionally, along with the foot pedal and the deadman handle, the trains are fixed with task linked vigilance, which rearranges a timer each time certain controls are activated by the driver (Bradt et al. 2015). If no changes happens in the control, a fluctuating lamp and then a buzzer sound and then the driver is needed to acknowledge a button of vigilance. If the controls are not being utilised by the driver of the train for acknowledging the alarm of vigilance, the vigilance system is activated and creates an emergency application of brake (Michel and Gardiner 2014). For monitoring the actions of the guard and the driver and the speed of the train, the trains are added with data loggers. The G7 was also implemented with the above mentioned system, but it was executed in the earlier stages of the initiation of the deployment of the fleet, and therefore, it was not commissioned and switched on during the accident (Jolly et al. 2014).
The rescue workers who visited the scene were restricted from accessing the passengers who were trapped on the train, as the workers did not possess the key that were required for opening the emergency exit doors. The mechanisms of emergency exit doors have been developed since then for allowing the doors to be utilised without the requirement of any kind of key. The mechanism of internal emergency door release has been installed by the RailCorp on all the new trains (Ramanathan 2016). Still, several passengers managed to escape from the closed doors as the train was damaged in 3 pieces due to the accident. ATP or Automatic Train Protection is considered to be beneficial for preventing the accident.
The professional code of conduct that was breached in this accident was the safety and security of the passengers in the train. The fatalities took place due to the negligence of the drivers and the higher authority. The trains were not properly examined and analysed prior to the deployment and this led to the severe accidents and even deaths. If proper preventive measures were applied in the system of the trains, the injuries could have been avoided (Day 2016).
Jnaneswari Express train derailment
The derailment of the Jnaneswari Express took place on 28 May 2010 in the state of West Bengal in India (Jehan 2014). The dispute in this derailment was that whether it was a sabotage or it was a bomb attack that caused the damage to the railway track, which led to the derailment of the train in front of an oncoming train of goods that hit the loose carriages leading in the death of at least 141 passengers.
Just a few weeks prior to the incident, the Indian Prime Minister, Dr. Manmohan Singh claimed that the attacks by the Naxals were affecting the profitability of the railways. The Prime Minister claimed that the government had invested almost Rs. 5 Billion for the extermination of the naxals and recover from the damages that were caused by the naxals (Peng et al. 2014). It was discovered that the naxals and their actions had made adverse effects on the operations, the loading of the freights and passenger traffics on a localised basis because of the threats and attacks caused by the naxals. The derailment occurred after 90 minutes after the party of Communist Party of India or the CPI(M) called a strike of four days in the region where the train was travelling through. The week was termed as a black week and the security was tasked on high alert (Zohar 2014).
The chief of the police of the state claimed that the responsibility was claimed by the Maoist naxalites for the removal of a length of 18 inches of the railway track. Approximately at 01:30 local time, a train that was carrying 13 carriages missed the track while passing over it and got derailed (Amador-Jimenez, Mohammadi and Nasiri 2017). The concerned train was travelling from the station of Howrah in West Bengal to the Mumbai station of state Maharashtra. A freight train that was travelling from the opposite direction hit the express train that was already derailed and that led to the death of several more passengers. It was later investigated that at least 141 deaths occurred from that incident and more than 180 were severely injured (Turner 2014). It was discovered that the train had just left a station and then it was just in between two stations when the derailment took place. After investigation, it was found that a significant section of the track was missing the fishplates were not firmly placed, and this suggested that the sabotage had taken place. Initially, the uncertainty that was analysed was that the reason of the attack was a blast or it was due to the train derailment. The Minister of Railways claimed that a bomb blast was the part of a calculated attack that caused the derailment of the train (Kujur 2017). It was found that the drivers heard the sound of an explosion and the Maoists had the access to several complicated bombs and improvised devices for explosion.
According to the official authorities, 26 dead bodies were discovered, and a team for rescuing was tasked for discovering additional bodies. The helicopters of Indian Air Force were called for duty on the spot of the accident and they airlifted several injured passengers to the nearby hospitals (Hegarty and Brodbeck 2017). Undertaking the initiative, the NCC mobilised several of their cadets for the operations of rescue and relief at the site of the accident. Despite being on holidays, the NCC managed to mobilise over 200 cadets for the task and they were successful in rescuing a significant number of injured passengers (Maclachlan 2015). They performed the task with the collaboration of the team of National Disaster Management and tirelessly provided the services that they were tasked of rescuing in almost 3 days. The task of the cadets were:
- Blood donation
- Crowd management
- Organising the services of food distribution and the facilities of water with collaboration with the locals
- Assisting the team of Disaster Management with the respective equipment of the rescue operations
- Migration of the injured people
- Assisting the hospitals and nurturing of the patients
- The guarding and the removal of the luggage that was recovered from the train
In addition to these teams, a team of medical officials were given duty in the location and it is also considered that the team managed to save many injured passengers from facing death.
During the investigation of the train derailment, it was discovered that several members of the militia also known as PCAPA were involved in the derailment case and some other members of the militia group were arrested and prosecuted. Furthermore, the case was transferred to higher investigation authorities, known as CBI for the forensic of the discovered evidences (Sharma 2016).
After the investigation was completed by the police of the state of West Bengal, it was established that the sole responsible of the accident were the Maoists who tried to disrupt the functioning of the government and create chaos among the people. Several posters were discovered from the area of Maoist majority saying that the PCAPA claimed the responsibility at that site (Bunker 2015). A spokesperson of thee PCAPA denied the involvement of the group in the accident and instead began blaming the ruling party for hatching a plot to create disruption the Minister of Railways and create distance among the Maoist group and the sympathies of the people. Sequentially, several other members of the group were arrested and the government finally managed to arrest all the involved individuals.
The Prime Minister of the ruling party expressed and shared his condolences over the loss of life. The Indian government provided the families of the dead an amount of Rs. 500,000 for the recovery and rehabilitation of the members of the family. The West Bengal state government announced the duty of bearing the treatment cost of the injured passengers. The Finance Minister of the country fated the attack although the blame was not directed towards the Maoist groups completely. The Finance Minister was reluctant to accept the fact that a bomb blast created the derailment even though several others Minister of the cabinet assured that the explosion was the major reason for the blast. The Indian Railway Minister rushed to the scene of the accident and also claimed to have the knowledge of the black days of the Maoists and there had been a significant rise in the implementation of the security officials near the station where the incident occurred.
The attack was condemned by the Chief Minister of West Bengal. The claim that was presented was that all the efforts has been directed against the menace; and on the mitigation techniques of the threat for the State and country. He also claimed that the forces will be sensitised and the counter-measures for the threat will be deployed for the threat from Maoists.
Blame-game of the political parties
Later after the attack, the ruling party and the opposition party engaged in political war that was connected to the upcoming elections for the municipal authorities in the province. The ruling party attempted to blame the opposition party claiming that the opposition party was trying to weaken the position of the ruling party before the elections and trying to sabotage the election campaigns that were being conducted in the area of the accident. This led to a major clash among the parties and the stability of the government was weakened.
The professional code of conduct was breached as proper care was not taken of the injured people and proper security measures was not provided to prevent the blast, which caused the derailment. The Maoist threat needed to be answered prior to the accident and the mitigation needed to be placed in proper places for the safety of the people. The honesty among the ruling authorities had to be transparent for creating a calm condition for the injured people and the families of the people who lost their family members.
Several changes have been implemented by the Railway authorities for creating the journey of the passengers more safe and secured. The monitoring of all the stations in real time situation are implemented to check the conditions of the tracks and the authorities have been tasked with additional duties for securing the train journeys. The higher authorities have to maintain the proper communication flow among the employees so that the rescue operations for any kind of incident can be deployed instantly and reduce the loss of lives. The mitigation techniques of the Maoist threat have been implemented to reduce the damages that can be caused by the Maoists. Government have implemented modified monitoring devices for monitoring the trains and the condition of the tracks (Romaniuk and Webb 2015).
Comparison of the case studies
In the first case study of the Waterfall rail incident, it can be discovered that the cause of the incident was the fault in the technical devices and the callousness of the drivers and the guards. The application of the deadman’s pedal was not done properly and while the train was taking a turn, the train was derailed and it led to the loss of life. In the second case study of the Jnaneswari express, the Maoists caused the derailment of the train by creating disruption in the track on which the train was travelling. In both the case studies, it can be discovered that the government implemented several changes in the trains and the stations to prevent any further mishaps.
It may be concluded that the reason for the derailment of the trains in both the case studies led to the loss of lives at a significant scale. The Waterfall rail incident derailed during taking a turn at a relatively high speed and passengers were harmed and in the case study of the Jnaneswari Express, the Maoists created the derailment of the train and several people lost their lives and many others were severely injured. The technical problems in the deadman’s pedal and the negligence of the driver and the guard to properly drive the train led to the derailment. After the Waterfall rail incident all the trains of CityRail were modified with the implementation of safety failure. The trains were fitted with data loggers for monitoring the actions of the guard and the driver and the speed of the train.
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