Rail Safety Investigation - Incorrect placement of worksite protection and near hit with worker - Otford - 29 June 2021

View the Rail Safety Investigation Report

What happened

On Tuesday 29 June 2021, NSW Trains passenger service C348, a four-car H set, was on a journey from Port Kembla to Waterfall when it encountered a lone rail safety worker on the Up Illawarra line between Otford and Helensburgh.

What we found

• the PO4 was unfamiliar with the location and became disoriented and placed the protection on the incorrect track
• Sydney Trains had a PO Network Familiarisation project underway that was yet to be integrated into normal operations
• a recommendation from the Transport for NSW (TfNSW) and Sydney Trains Risk Based Training Needs Analysis report for POs (2016) to implement a training and certification regime that included local knowledge as an integral part of gaining approval to work on the network was adopted but only partially implemented
• the Network Rules and Procedures for Track Occupancy Authority did not provide for location assurance for workers placing or removing protection.

What has been done as a result

The recommendations investigators made include:

• reviewing the Network Rules and Procedures, Asset Maintenance, Network Maintenance and Major Works procedures regarding verification of location and develop a best practice model to be implemented when placing protection across the Sydney Trains network
• reviewing “Using railway track signals” (NPR 709) with a view to include (where practicable) the requirement for a Qualified Worker to verify their location prior to placing RTS
• ensuring relevant training and assessment is updated to reflect any changes to Network Rules and Procedures that specify verification of location when placing protection
• ensuring the Worksite Protection Guideline is updated to reflect any changes to Network Rules and Procedures that specify verification of location when placing protection
• investigating the use of the Track Augmented Reality View solution in the specified. It is noted that there may be satellite connection issues due to topography; however, this will be tested as part of the investigation
• engaging Human Factors (HF) support to conduct a review of the effectiveness of documents and tools used by all for worksite protection planning. This should include a solution that allows for sharing of worksite information in a standardised, clear and easy to use, and easily accessible format
• that a copy of this report is provided to Swetha for shared learnings between the organisation.