The day of the roses

Those who do not move, do not notice their chains

Rosa Luxemburg 1

imageMany elderly Australians never forget Granville and can vividly recall the moment news broke with reports of the horrific carnage on that fateful January morning back in 1977. The disaster unfolded within seconds although it was a decade or more in the making via budgetary constraints, especially on rail infrastructure and maintenance expenditure. Its aftermath provided valuable lessons, especially covering emergency response, pathophysiology, psychological welfare and pastoral care. 28

The passenger train from Mount Victoria in the Blue Mountains was packed with early morning rush hour commuters. After leaving Parramatta, the engine with its eight carriages entered a deep narrow cutting and negotiated a curved track as it approached Granville railway station. The locomotive suddenly derailed and demolished several support stanchions of an overhead bridge. Its leading coaches were dragged from the rails as the engine toppled and slithered to a halt on its right hand side. The first carriage struck a severed power pylon and the boxcar was ripped open like a can of pilchards, killing eight people instantly. Every passenger in the second carriage survived without suffering any serious physical injuries although psychological trauma was inevitable. 914

The Bold Street overpass carrying four vehicles immediately above the tracks briefly shuddered before the reinforced concrete decking collapsed onto the third and fourth railway carriages below and crushed many of the occupants. It claimed the lives of 84 passengers, which included an unborn child and left countless victims physically injured and emotionally shattered. Like the majority of transport disasters, it unravelled almost spontaneously and despite a formal inquiry, it bequeathed an abundance of unanswered questions and changed the lives of so many people forever. The inquiry exonerated the locomotive driver who survived the ordeal along with several colleagues and the motorists on Bold Street bridge. 1518

 

The original inquiry identified the unsatisfactory condition of the permanent way and substandard rail fastening as a significant contributory factor. It enabled the track to splay beyond its gauge, which displaced the locomotive’s left front wheel although more recent research and anecdotal evidence suggests a defective front wheel on the locomotive required replacement. However, auxiliary components and many other spare parts were sold for scrap to raise funds and the engine continued operating under surveillance. This curtailed maintenance expenditure and fulfilled stringent state rail transport budgetary constraints until Murphy’s law raised its head. 1922

The state Public Transport Commission’s budget deficit amounted to millions of dollars each year and the maintenance of rail infrastructure and rolling stock was sadly neglected, which was quite evident via the uncleanliness of its threadbare rail carriages. This was exacerbated via the continual exchange of track inspection crews over many months preceding the disaster. Other contributing factors included the structural design and features of the Bold Street concrete overpass, especially the precarious location of support stanchions. Investigations also revealed the bridge had been struck previously by a derailed locomotive some ten years ago and more recently in 1975 by a loaded coal wagon. 2327

Rescue crews were praised for their professionalism under such extremely difficult conditions although a debriefing exercise almost a month later raised several concerns. Emergency response teams including the state police rescue, fire brigade and ambulance services arrived at the scene and encountered the unenviable task of removing corpses from the crushed and flattened carriages. The narrow rail cutting restricted access and efforts were somewhat compromised by the structural integrity of the overhead bridge and its unstable remaining sections. This required cutting and grinding equipment to dismantle entire segments of the collapsed reinforced concrete decking and the use of mobile cranes and other lifting and load bearing devices. 2835

Risks were exacerbated by the unnecessary accumulation of spectators, stifling summer heat, high voltage electricity and an unanticipated bulk storage of liquefied petroleum gas. This was used to heat carriages during winter months and the flammable compressed gas began leaking from damaged cylinders and fractured pipelines. It required application of water sprays to reduce the risk of fire or explosions whilst using oxyacetylene cutting equipment during the rescue operation and the last body was eventually removed from the wreckage some thirty hours later. 3641

 

Several trapped passengers suffered traumatic rhabdomyolysis or crush injury syndrome and succumbed to the ensuing complications following accumulation of toxins, which caused heart and kidney failure. There was no structured or formal arrangements covering psychological support or pastoral care for emergency response crews. Many team members reported symptoms of anxiety, insomnia and depression almost a month later following their harrowing experiences at the disaster scene. 4244

After the inquiry, recommendations from Justice Staunton included the provision of disaster and crisis management training for emergency services and social welfare groups. This involved establishment of the National Association for Loss and Grief, which provided support for rescue personnel affected by the disaster. The late Neville Wran, who was appointed as state premier for New South Wales just before the disaster, borrowed heavily to renovate the ailing state rail infrastructure via a substantial $200 million improvement plan. 4550

The Bold Street overpass and other similar structures were progressively replaced by single span bridges, which eliminated requirements for trackside support stanchions. Other fleet maintenance initiatives included installation of automated carriage washing facilities at the Flemington, Punchbowl, Mortdale and Hornsby depots. These were recently modified and additional amenities were provided at the Sydenham yard to accommodate diesel operated trains. 5158

Following the tragedy, the profound grief and suffering was immeasurable and a voluntary group established a memorial trust although it was never officially registered. Donations were received from many anonymous sources, which enabled the organisation to erect a memorial wall near the site and hold annual commemorative services. Each year the emotional ceremony ends on Granville’s Bold Street bridge and red roses are scattered onto the railway tracks below to remember the many victims who never made it home on that fateful day. 5962

 

During the 30th anniversary remembrance service an additional commemorative plaque was unveiled on Bold Street bridge by the state transport minister to acknowledge the assistance of many rail workers during the disaster. Almost a decade later in 2016, the Granville Train Disaster Association, was officially established to coordinate subsequent events, which unfortunately coincided with the amalgamation of several local government councils, restructuring and reallocation of jurisdictions. The memorial site and annual commemoration were not officially recognised under the administrative arrangements of a recently established Cumberland Council. Its impassive panjandrums merely instructed the association to apply for a council grant to guarantee continuation of the remembrance services, which offended several volunteers and upset many bereaved dependents. 6367

In January 2017, survivors, relatives and rescuers gathered for the 40th anniversary of the disaster in Sydney’s western suburbs. It included a church service at St Marks Anglican Church in Granville before proceeding to the memorial garden and culminated in the red roses ceremony from the Bold Street bridge overpass. 6971

On the 4th May 2017 the state premier acknowledged the often callous or insensitive treatment afforded to many of the victims under Neville Wran’s leadership and a formal apology was issued in the New South Wales parliament. At a recent Cumberland council meeting its newly elected councillors unanimously agreed to provide support for the commemorative service and request assistance from the state government and Parramatta City Council. Many of the bereaved families, survivors and other victims were disregarded and felt neglected for many years after the disaster and the following poignant lyrics from The Rose resonate: 6879

When the night has been too lonely and the road has been too long

And you think that love is only for the lucky and the strong

Just remember in the winter, far beneath the bitter snows

Lies the seed, that with the sun’s love, in the spring becomes the rose

 

Since Granville, Australia’s population has increased by 44% to 25 million people and the scale of its rail transport network, especially throughout its major cities has escalated accordingly. Improved design and technology may have reduced the objective risk and most public and private rail network operators have implemented systems that employ a positive degree of control, which is validated via an absolute and vigilant attention to safety. It indicates risk is decreasing on a total industry sector basis irrespective of growth and is typically expressed as the number of fatalities each year attributed to rail transport. However, while the network continues operating the risk will never be eliminated and any light at the end of the tunnel may well be a freight train. This is reflected by a more recent series of high profile rail disasters across the United Kingdom and in Australia. These include Clapham (1988), Cowan (1990), Southall (1997), Glenbrook (1999), Ladbroke Grove (1999), Hatfield (2000), Potters Bar (2002) and Waterfall (2003). 8094

Most rail disasters attract extensive media coverage, which initially amplifies subjective risk and it is often exacerbated through social media platforms and repetitive 24/7 news broadcasts although it is rapidly attenuated by the voice of the powerful. The confected public outrage inevitably generates a hollering for justice or closure via corporate manslaughter or culpable homicide legislation. It merely creates a lawyer’s picnic and fans the flames on the carousel of culpability breeding more blame and fear. Freedom, awareness and intention are critical elements in the establishment of criminal liability and the attribution of corporate manslaughter is fraught with legal complexities. Moreover, the act is not culpable unless the mind is guilty and the dilemma was quintessentially addressed by the Lord Chancellor of Great Britain, Edward Thurlow back in the 18th century who proclaimed that corporations have……….…….No soul to damn and no body to kick. 95103

The Clapham Junction rail crash in 1988 was Britain’s worst rail disaster and attracted extensive media coverage. British Rail received a £250,000 fine for breaching statutory legislation although there were no prosecutions for manslaughter. Almost a decade later on 19th September 1997, the Southall disaster in west London involved the collision of an intercity express with a freight train. The passenger train’s automatic warning system was isolated and the driver failed to notice cautionary signals and was unable to apply the brakes promptly. 104106

Great Western Trains received a £1.5 million fine for breaching statutory safety legislation although charges of manslaughter by gross negligence against the intercity express train driver were eventually dropped. Following the Hatfield rail disaster in Hertfordshire, Network Rail and Balfour Beatty received substantial penalties for breaching statutory safety requirements. Both organisations were excoriated for their cavalier corporate culture although manslaughter charges against several senior executives were subsequently dismissed. Two years later in 2002 the derailment of an electric train with four carriages at Potters Bar killed seven people and Network Rail received a £3 million fine. 107113

These disasters influenced the introduction of corporate manslaughter legislation in the United Kingdom. However, it is not just a question of ethics, intent or morality but also a matter of leadership. The structural levels at which organisational culture is addressed and how it manifests is paramount. More legislation typically generates blame and fear, which undermines common law and extirpates immeasurable traits such as trust, respect and humility. The only safe ship in a storm is leadership, which often relapses into intimidation, especially when extraordinary executive performance bonuses are at risk. It begs the question how can any organisation be considered ethical if its only corporate social responsibility is to make a profit? 114123

The entrepreneurial and buccaneering US oil industry tycoon, John D. Rockefeller somewhat predictably embraced a laissez faire spirit towards disasters, which encouraged the transformation of adversity into opportunity. This commodification was reflected following the World Trade Centre attack in the financial district of downtown Manhattan. A dedicated memorial features twin commemorative pools and has lured over 30 million visitors since its inauguration in 2011. The not for profit venture with its beguiling complementary museum officially opened in 2014 and attracts almost 9000 people each day. A $69 admission fee generates over $200 million each year although the cost of fitting aircraft cockpits with substantial doors and strong latches was a modest $3000 per plane. 124128

 

In 1989 a senior executive with Liverpool Football Club was preoccupied with the Hillsborough disaster, especially regarding its impact on the club’s re-entry to European competition following a prolonged suspension after the Heysel stadium tragedy some four years earlier. Although funeral arrangements for many of the Hillsborough victims remained uncertain, a somewhat callous and injudicious English Football Association demanded the abandoned fixture be replayed almost immediately. During the prolonged justice campaign, established support groups were required to hire meeting rooms from Liverpool Football Club, which was then owned by American entrepreneurs George Gillett and Tom Hicks. It was eventually sold to Fenway Sports Group, a sophisticated and synergistic international sports conglomerate based in the United States at Boston, Massachusetts. 129137

This recurring theme of deplorable professional and business ethics using impersonal computer says no logic without a skerrick of care or compassion was quite evident in Australia, especially following the recent Dreamworld theme park tragedy near Queensland’s Gold Coast. Despite the corporate sincerity and its outpouring of confected grief the Ardent board charter depicts organisational values that are reminiscent of halcyon days at Sanctuary Cove with the notorious white shoe brigade. Its primary function is an obstinate deification of the mercenary Friedman doctrine. This…….….promote$ long term health and pro$perity of the group and build$ $u$tainable value for it$ inve$tor$, which is somewhat incongruous with the object of safety legislation. It was depicted by deplorable crisis management protocols and woeful behaviour from a didactic chairman and an embattled celebrity chief executive officer in a nefarious attempt to protect reputations and secure lucrative performance bonuses. 138149

Dreamworld planned to reopen the theme park even before the blood had been washed from the surrounding concrete. It was only postponed because the site was classified as a crime scene under a warrant from the Queensland Police Service. An early opening may have compromised the forensic investigation and the company was forced to issue an embarrassing apology during the media maelstrom. It decided to wait until after the funerals and completion of the complex investigation. Ardent Leisure held its annual general meeting in Sydney several days after the tragedy and its socially autistic chairman stepped down amidst the crisis. The chief executive officer donated a recent cash bonus of almost $170,000 to the Red Cross for the support of bereaving dependents. However, the board approved a $843,000 performance incentive scheme, which included substantial cash payments over several years to quench a ravenous maw. Claims that police and Dreamworld had contacted all of the families were disputed by close relatives during a press conference following the meeting. 150157

 

The opprobrium escalated as the organisation attempted to block the release of sensitive documents under freedom of information. The site remained closed for almost seven weeks and the Queensland Police Service in its report to the coroner recommended no criminal charges be brought against Dreamworld theme park employees. A coronial inquest commenced at Southport courthouse in June 2018 and Deborah Thomas, the former chief executive officer with Ardent Leisure, received almost $3000 per day to attend the inquest. Soon after the hearing opened, the Dreamworld chief executive officer resigned and was rewarded via a lucrative sinecure with the Gold Coast Tourism Corporation at Destination Gold Coast. Meanwhile, it is over three years since the tragic event and the coronial inquest report remains unpublished. 158166

More recently following the Boeing 737 Max aircraft disasters the organisation’s socially autistic chief executive officer, Dennis Muilenburg admitted its manoeuvring characteristics augmentation system activated in response to erroneous angle of attack data. This left pilots operating in the dark with mere seconds to execute correct decisions and perform recovery manoeuvres. The software was installed aboard its 737 Max aircraft without any documentation or disclosure to pilots. It is unconscionable that Boeing, the Federal Aviation Administration and many airline companies had pilots operating aircraft without sufficient training and flight manuals devoid of any critical information pertaining to the software operating system. 167170

Following the Lion Air and Ethiopian Airlines disasters Boeing eventually established a US$50 million compensation fund for the bereaved families. In 2018 its chief executive officer received a substantial remuneration package, which exceeded US$23 million. It included a base salary of about US$2 million supplemented by stock options and performance bonuses with other perquisites and gratuities. This amounted to almost 50% of the designated compensation fund with a base salary that was over tenfold greater than the benefits awarded to the individual families of each victim and the poignant lyrics from yet another Bob Dylan classic resonate…….Money doesn’t talk it swears: 171175

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Bernard Corden

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4 Replies to “The day of the roses”

  1. Unfortunately I think Safety thinks ‘laissez faire’ is a school fundraiser as it has no interest in politics. I am reminded of the lyrics of that great political band Midnight Oil – short memories!

  2. Unfortunately I think Safety thinks ‘laissez faire’ is a school fundraiser as it has no interest in politics. I am reminded of the lyrics of that great political band Midnight Oil – short memories!

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