Rail Safety Investigations

In the event of the Chief Commissioner of the ATSB not initiating an investigation into a rail safety occurrence, OTSI's Chief Investigator has the discretion to choose whether or not OTSI will investigate. Additionally, the NSW Minister for Transport may direct that an investigation takes place. In determining what to investigate, the Chief Investigator considers the following aspects:

All investigations conducted by OTSI are solely for the purpose of identifying why an accident or incident happened and to make recommendations to prevent a similar occurrence happening in the future.

As a result of this objective, investigations are conducted within a 'just culture' that does not seek to apportion blame. However, if it is apparent that the safety occurrence was the direct result of a malicious act, then the matter will be passed to the appropriate regulator or enforcement agency.

As an investigation nears completion, a draft investigation report will be circulated to all Directly Involved Parties for comment. The purpose of this consultation is to provide these parties with the opportunity to identify matters that they believe warrant additional consideration. The Chief Investigator will consider such matters but is not obliged to reflect them in the final report. The final report is forwarded to the Minister for Transport for tabling in both houses of the NSW Parliament. Shortly after tabling, the report is published below.

Investigation Reports

Date Location Description Status Report
2 December 2016 Muswellbrook - 443 Kb PDF Disabled Xplorer Service NP23 In Progress Interim
10 August 2016 Sydney Central Station - 117 Kb PDF Passenger Fatality In Progress Interim
21 April 2016 Moorland - 976 Kb PDF Level Crossing Collision Complete Final
19 January 2016 Denman (investigation under TSI Act 2003) Derailment In Progress
17 December 2015 Hornsby (investigation under TSI Act 2003) Derailment In Progress Interim
14 September 2015 Hawkesbury River Railway Bridge - 833Kb PDF Safe Condition of Bridge Complete Final
28 August 2015 Pangela (investigation under TSI Act 2003) Derailment Complete Final
18 June 2015 NSW Rail Incidents 2004 - 2013 - 4.52Mb PDF Contributing Factors Complete Final
12 March 2015 Mt Druitt (investigation under TSI Act 2003) Wrong Running Direction Complete Final
15 Feb 2015 Kankool [investigation under TSI Act 2003] Coal Train Derailment In Progress
24 Nov 2014 Warnervale [investigation under TSI Act 2003] Incident Involving ASB Complete Final
10 October 2014 Boronia No. 3 Tunnel - 951Kb PDF Main Line Rail Defect In Progress Interim
2 August 2014 Flemington Maintenance Centre - 1.79Mb PDF Worksite Protection Incidents Complete Final
5 June 2014 Awaba (Investigated under TSI Act 2003) - 1.33Mb PDF Locomotive Fire Complete Final
22 May 2014 Kilbride [investigation under TSI Act 2003] Safeworking Breach In Progress
31 Jan 2014 Currabubula - 7Mb PDF Derailments Complete Final
15 Jan 2014 Edgecliff [investigation under TSI Act 2003] Derailment of Passenger Train Complete Final
21 Dec 2013 Moss Vale - 1Mb PDF Safeworking Incident Complete Final
27 Nov 2013 East Maitland - 1 Mb PDF Safeworking Incident Complete Final
10 July 2013 Revesby [investigated under TSI Act 2003] Safeworking Breach Complete Final
13 June, 13 & 17 July 2013 Blackheath, Newcastle & Wollstonecraft (investigated under TSI Act 2003) Safeworking Breaches Complete Final
21 May 2013 near Moree - 2 Mb PDF Level Crossing Collision Complete Final
30 Jan 2013 Hurlstone Park [investigated under TSI Act 2003] - 631 Kb PDF SPAD Complete Final
3 Jan 2013 Rennie - 631 Kb PDF Grain Train Derailment Complete Final
5 Dec 2012 Gulgong - 2.08 Mb PDF Wagon Structural Failure Complete Final
28 Nov 2012 Boggabri - 2 Mb PDF Coal Train Derailment Complete Final
17 July 2012 Summit Tank to Dombarton Section - 524 kb PDF Safeworking Incident Complete Final
18 May 2012 Bengalla to Mangoola Section - 3.67 Mb PDF Ballast Train Collision Complete Final
4 May 2012 Nundah - 3 Mb PDF Level Crossing Collision Completed Final
7 March 2012 Gunnedah - 749 kb PDF SPAD and Opposing Movement Complete Final
27 Feb 2012 Narromine - 2.62 Mb PDF Level Crossing Collision Complete Final
12 Dec 2011 Unanderra - 653 kb PDF Safeworking Incident Complete Final
23 Nov 2011 Clifton - 2.27 Mb PDF Derailment Complete Final
2 Sep 2011 Woy Woy - 1.1 Mb PDF Train collision with car Complete Final
3 May 2011 Enfield Yard - 1.35 Mb PDF Runaway Rolling Stock Complete Final
1 Apr 2011 Lithgow - 1.39 Mb PDF Collision Complete Final
7 Feb 2011 Unanderra - 537 kb PDF Uncontrolled Movement Complete Final
29 Oct 2010 Bankstown - 987 kb PDF Near Miss Complete Final
1 Sep 2010 Wee Waa - 1.78 Mb PDF Level Crossing Fatality Complete Final
13 Apr 10 Kogarah - 206 kb PDF Track Worker Fatality Complete Final
11 Apr 10 Woy Woy - 902 kb PDF Equipment failure Complete Final
1 Apr 10 Strathfield - 1.99 Mb PDF Near Strike Complete Final
13 Mar 10 Whittingham - 1.72 MPDF Derailment Complete Final
27 Feb 10 Darling Park - 2.8 Mb PDF Monorail Collision Complete Final
28 Oct 09 Glenlee - 2.49 Mb PDF Safeworking Breach Complete Final
28 Jul 09 Temora - 2.6 Mb PDF Runaway Wagon Complete Final
10 May 09 Goobang Junction - 2.23 Mb PDF
Attachment - Lochinvar Incident Investigation - 3.72 Mb PDF
SPAD and Collision Complete Final
8 Feb 09 Narromine to Parkes Section - 5.24 Mb PDF Derailment Complete Final
24 Jan 09 Unanderra - 1.67 Mb PDF Derailment Complete Final
7 Jan 09 Homebush - 4 Mb PDF Derailment Complete Final
24 Sep 08 Duri - 214 kb PDF Fatality Complete Final
29 Jan 08 Breeza to Werris Creek Section - 1.49 Mb PDF Derailment Complete Final
16 Jul 07 Singleton - 2.77 Mb PDF Fatal Rail Accident Complete Final
8 Feb 07 Connemarra - 1.91 Mb PDF Derailment Complete Final
14 Jan 07 Euabalong West - 4.5 Mb PDF Derailment Complete Final
11 Jan 07 Leeton - 5.11 Mb PDF Derailment Complete Final
7 Nov 06 Sandgate - 1.24 Mb PDF Track Working Injury Complete Final
01 Oct 06 Nevertire - Nyngan Rail Section - 2.01 Mb PDF Derailment Complete Final
11 Sep 06 Thirroul - 2.19 Mb PDF Derailment Complete Final
02 Sep 06 North Strathfield - 1.27 Mb PDF Opposing Movement Complete Final
30 Aug 06 Central to Town Hall Tunnel - 354 kb PDF Fatality Complete Final
22 May 06 Vicinity of Baan Baa - 1.22 Mb PDF Track Worker Fatality Complete Final
15 Apr 06 Ariah Park - 2.09 Mb PDF Shunting fatality Complete Final
04 Nov 05 Lidcombe - 1.25 Mb PDF Derailment Complete Final
16 Oct 05 Conoble to Ivanhoe - 1.89 Mb PDF Derailment Complete Final
27 Apr 04 Steel Sleeper - 2.23 Mb PDF Safety Complete Final
20 Aug 05 Bloomfield - 1.69 Mb PDF Safety Complete Final
04 Jul 05 Clarence - 587 kb PDF Accident Complete Final
31 May 05 Grawlin Plains - 1.08 Mb PDF Collision Complete Final
06 Apr 05 Old Burren - 3.3 Mb PDF Derailment Complete Final
07 Mar 05 / 01 Mar 05 Wauchope / Lapstone - 864 kb PDF Derailment Complete Final
22 Dec 04 Bethungra - 1.1 Mb PDF Derailment Complete Final
01 Jul 04 Port Botany - 1.2 Mb PDF Shunting fatality Complete Final
04 May 04 Baan Baa - 1 Mb PDF Collision Complete Final
20 Jun 03 Unanderra
Part 1 - 902 kb PDF
Part 2 - 1.47 Mb PDF
Derailment Complete Final
19 Nov 02 Yass Junction
Part 1 - 1.58 Mb PDF
Part 2 - 1.08 Mb PDF
Part 3 - 2.18 Mb PDF
Derailment Complete Final
07 Nov 02 Rocky Ponds
Part 1 - 1.19 Mb PDF
Part 2 - 1.09 Mb PDF
Part 3 - 1.09 Mb PDF
Derailment Complete Final