Coroner blames Metro for elderly man’s death

Metro’s failure to alert a train driver about an elderly man on the tracks contributed to a fatal collision, a coroner has found.
Nanjing Night Net

Coroner Paresa Spanos found Werner Viertmann’s 2012 death was preventable, as Metro’s central control centre could not contact the train driver in the five minutes between being alerted of the elderly man’s presence near the tracks and the collision.

Mr Viertmann, 83, died when hit by a train at Laburnum station, in Blackburn, about 2.45pm on October 4, 2012. It is believed his diminished cognitive capacity led to him to wander near the tracks.

A train driver who saw Mr Viertmann alerted Metro’s control centre, Metrol​, but was not advised to stop his train.

A drop-out within Metro’s urban train radio system (UTRS) and the inability of Metrol​ controllers to contact the driver of a second train meant Mr Viertmann was hit.

The curve of Laburnum station’s platform also meant the driver didn’t see the man until it was too late.

“It is tolerably clear that had the driver of (the second train) been alerted to Mr Viertmann’s presence near the tracks in a timely way, the collision and Mr Viertmann’s death may well have been avoided,” Ms Spanos wrote in findings released by the Coroners Court on Monday.

The coroner found that besides the unreliability of the UTRS, Metrol​ controllers used their precious minutes inefficiently, as they misinterpreted Mr Viertmann’s location, called back the first driver for clarification, lingered too long on an unrelated call from another driver and did not obtain the mobile phone number for the second driver.

“Human error on the part of Metrol​ staff and the systemic failure of the UTRS network prevented (the second) driver from receiving a warning that Mr Viertmann was near the tracks close to Laburnum station and so contributed to the collision,” Ms Spanos wrote.

Ms Spanos found Mr Viertmann would not have been hit had the first train driver waited at Laburnum. It wasn’t clear why he wasn’t advised to do so, she said.

Metro has since replaced the UTRS network with a digital radio system, Ms Spanos said, and Mr Viertmann’s death could have been prevented had this improved system been in place in 2012.

The train operator has also developed a more detailed policy about what train drivers and Metrol​ operators should do when people are seen on tracks, the coroner said.

But a cultural shift was needed, she said, for Metrol​ operators to encourage drivers to stop when people ventured on to tracks rather than just be on alert.

The names of the Metrol​ operators were anonymised​ in Ms Spanos’ findings. Fairfax Media has chosen not to name the drivers involved.

In 2012 Metro recorded 1402 reports of trespassers on tracks across its network, which led to 37 deaths, the coroner found. The train operator is not obliged to erect fencing.

This story Administrator ready to work first appeared on Nanjing Night Net.

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