Rail Worksite Protection in NSW - Report 1- Picton -16 August 2022

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What happened

On 16 August 2022, NSW Trains Endeavour passenger service SN42 travelling from Moss Vale to Sydney departed Picton platform and encountered an excavator on the Up Main line approximately 300 m ahead.

The Protection Officer (PO) had authorised the handsignaller closest to the worksite to permit SN42 to travel unrestricted, however the PO also permitted the excavator operator to occupy the track before the train had passed safely through the work area. 

The potential consequence was a loaded passenger train striking a piece of heavy equipment at speed, putting at risk not only the operator of the excavator, but also the people on the train should it derail and overturn. 

What we found

Contributing factors leading to human error and limitations on human performance were highlighted in this incident.

The investigation made several observations including:

• the PO lost situational awareness while managing the work due to a range of factors, including high cognitive workload, fatigue, and the noisy, distracting location of the work
• the ARTC rules and procedures for managing TWA do not contain specific details in how to manage rail traffic through a worksite.

What was done as a result

Since the incident, ARTC has advised the following safety actions are in progress or completed: 

• Undertake a review of the NSW TWA rule and procedure. The review to include applicability of process to positively identify rail traffic as clear of a work site.
• Updated procedure COR-PR-029 that supports and reinforces the requirements of ANWT 306.

The Systemic Investigation into worksite protection in NSW is progressing. To date, OTSI has:

• gathered and undertaken analysis of data relating to worksite protection incidents in NSW
• reviewed a number of transport operator investigation reports for common causal factors
• reviewed previously published investigation reports by OTSI, ATSB and other transport safety bodies
• interviewed interested parties and stakeholders
• reviewed the safety management systems of the major Rail Infrastructure Managers in NSW as they apply to worksite protection
• reviewed bodies of research applicable to the application of technologies for worksite protection.

The investigation is continuing and will include:

• further detailed examination of the safety management systems of the Rail Infrastructure Managers in NSW
• examination of the uptake of technology solutions to improve the performance of worksite protection
• detailed analysis of the common causal factors for worksite protection incidents.

Should a critical safety issue be identified during the investigation, OTSI will notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.