The Inquiry into the Waterfall train crash: implications for medical examinations of safety-critical workers

Bruce Hocking
Med J Aust 2006; 184 (3): 126-128. || doi: 10.5694/j.1326-5377.2006.tb00151.x
Published online: 6 February 2006


  • The implications arising from the Inquiry into the Waterfall train crash for medical examinations of safety-critical workers are discussed.

  • Examinations need to be appropriate for the level of risk in the job and apply current medical thinking.

  • A careful balance is required between the various legal obligations, including duty of care, disability discrimination and privacy.

  • The frequency of examinations depends on a combination of medical, economic and logistical factors.

  • Health professionals who conduct examinations should be familiar with the occupation of the person being examined.

  • Ethical relationships with the worker’s general practitioner or specialist(s) must be observed.

  • The procedures associated with the examinations are as important in achieving safety as the actual examinations. These include complying with relevant standards; providing all relevant documentation with a referral for an examination; acting on the doctor’s report appropriately; and auditing the process.

On 31 January 2003, a suburban passenger train travelling from Sydney to Port Kembla left the track and overturned at high speed on a curve near Waterfall railway station (Box 1). The train driver and six passengers were killed and many of the remaining passengers were injured.

Between 2003 and 2004, an Inquiry (Waterfall Rail Safety Investigation) was conducted by the Honourable Peter McInerney QC to determine the causes of the accident and to identify any safety improvements to prevent further train accidents. The Inquiry made interim (2004) and final (2005) reports.1 It found that, apart from inadequacy of the “dead man’s” system, engineering factors relating to the track and rolling stock could be excluded as causes of the crash. (A “dead man’s” system is a device which should stop a train in the event of incapacitation of the driver.)

The Inquiry concluded that the driver had suffered an episode of ventricular fibrillation, as there was no evidence of an infarct on autopsy, although the left anterior descending artery was narrowed. The guard, who had not acted promptly when the train increased in speed, possibly had an anxiety–depression state that contributed to his inaction.

Deficiencies were found in, and recommendations made for, a wide range of rail-safety issues, including: design of rolling stock; training of drivers and guards; risk assessment procedures; emergency response preparedness; independence of the rail-safety regulator; and medical assessments for rail workers.

Medical assessments for rail workers

The Inquiry identified many deficiencies in the medical assessment system used by the rail company (Box 2), and there are several lessons to be learned from this Inquiry. These are relevant to both organisations who employ, and doctors who examine, people involved with safety-critical work. In safety-critical work, ill-health may have serious, immediate community impact. Such jobs include control-room workers in large chemical or nuclear power plants, public transport drivers and airline pilots, as well as drivers of dangerous goods vehicles. The recent Inquiry into a ferry disaster in New York, in which medical factors were causative, also found deficiencies in the system of medical examinations.2 The new Australian medical standard for rail workers gives one possible framework for managing medical examinations for safety-critical workers and has met with approval from the Waterfall Inquiry.3,4

Medical examinations of safety-critical workers need to be particularly designed to take into account the company’s duty of care to the public and other employees, as well as privacy and disability discrimination legislation. The factors that should be considered when designing such a medical examination system are discussed below and summarised in Box 3.

What examinations should be done?

The thoroughness of the examinations needs to be commensurate with the consequences in the event of illness occurring. Examinations should apply current medical thinking and be reviewed periodically; for example, the present national medical standards for rail workers and commercial vehicle drivers have a “sunset clause” of 5 years. All medical examinations involve a standard format of medical history, examination and relevant tests. The examination needs to focus on safety; questions and physical examinations not clearly relevant to safety in the work context, such as “men’s health”, should not be included, as privacy may be infringed. However, for efficiency, the examination may need to integrate related occupational health and safety concerns (eg, working with chemicals or noise).

In situations where sudden incapacity, like a heart attack, could lead to serious consequences, a quantitative and predictive risk assessment should be considered, such as that based on the American Heart Foundation cardiac risk score, with appropriate use of stress electrocardiography.5 If loss of concentration is an important consideration, tools such as the K10 assessment for anxiety and depression,6 and the Epworth Sleepiness Scale7 for excessive daytime sleepiness, may be useful.

Disability discrimination may be managed firstly by ensuring the examination criteria are clearly task-related and based on current medical thinking; and secondly by allowing for advice to be given to an employer, such as “fit, subject to regular review”, in the case of well controlled chronic diseases. Practical tests, which should be judged against pre-determined criteria, may be relevant for assessing people with musculoskeletal conditions or sensory deficiencies. However, it has to be recognised that practical test results are situation specific and cannot be generalised to other work settings.

The results of medical examinations may need to be integrated with the results of psychological assessments, and drug and alcohol screening tests.

The frequency of examination will be influenced by a mix of factors including the usual age at onset of the conditions of concern, the prognostic value of clinical data, the economics and logistics of the examinations, and public perception of risk. The desire to meet a duty of care should be tempered by considering the feelings of workers facing repeated examinations, and their fear of losing their jobs if they fail.

Whatever frequency of examination is set, ill-health may occur in between assessments and this needs to be managed. Organisations should establish a system to monitor safety-critical workers for markers of ill-health, such as escalating sick leave or incidents at work, and then arrange “triggered referrals” to a doctor. The system should also encourage self-referral for workers concerned about their health.

How should examinations be conducted?

The procedures associated with medical examinations are as important as the actual examinations. The development of a sound administrative structure is crucial to achieving an effective balance between the competing legal demands of duty of care, disability discrimination and privacy. In large organisations, both the health assessment process and the examinations should be subject to periodic audits involving the expertise of occupational physicians.

For employers, the process should include providing the examining doctor with any relevant information the organisation holds about the employee — sick leave record, drug and alcohol testing results, accident and incident reports — to give a total picture of health at work.

After the examination, the results should be explained to the employee and then conveyed to the employer in functional not diagnostic terms. This is partly because medical diagnostic information is confidential and must not be divulged without the employee’s agreement, and partly because the employer needs information meaningful to employment, not medical information which may be only partly understood. This is consistent with the privacy legislation. There needs to be a system in place whereby the employer is advised promptly if an employee is found to be unfit for safety-critical work, or has been identified at examination as needing frequent follow-up review. A doctor would want to follow up, for example, a safety-critical worker returning to work after commencing treatment for obstructive sleep apnoea or diabetes. Such a system also helps balance the duty of care and the disability discrimination obligations of the employer.

  • Bruce Hocking

  • Camberwell, VIC.


Competing interests:

I was the medical consultant to the National Transport Commission in the development of the new national medical standards for road8 and rail.3 I have been a consultant to RailCorp (NSW), and have conducted an external audit of the implementation of the national medical standards by RailCorp and its medical provider. I gave evidence at the Waterfall Inquiry.


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