Read the Rail Safety Investigation Report
OTSI conducted this investigation in collaboration with the ATSB.
What happened
- A NSW Trains passenger train collided with an abandoned vehicle, causing the first carriage to derail and tip over.
- The driver received serious injuries and two passengers in the lead carriage were also injured. They and the guard were taken to hospital for observation. The other eight passengers were assessed on site and medically cleared.
- Considerable damage occurred to the train, rail infrastructure, and overhead wiring.
What we found
- An individual was charged and pleaded guilty to endangering passengers and obstructing a railway, directly causing the collision.
- The individual tampered with CCTV cameras, which went undetected
- CCTV tamper alarms were not activated.
- A call about the vehicle on the tracks was not treated as an emergency by all parties and the actions taken to alert train crew did not afford time for the train crew to react and avoid the collision.
- The guard’s attempt to use the DTRS failed due to a tripped circuit breaker. The guard used a mobile phone to provide a timely report of the incident.
- Conflicting instructions in the Security Control Centre’s procedures potentially delayed communication.
- The guard identified the risk from live overhead wires and informed first responders to stay clear. There remained a risk to the guard and first responders who attended to the driver and injured passengers, with the potentially live 1,500 V overhead wires at ground level.
Actions taken by directly involved parties during the investigation
- Sydney Trains completed 14 internal and OTSI recommendations to address key safety issues from the incident.
- The Security Control Centre Standard Operating Procedure was aligned with the Network Incident Management Plan, requiring operators to contact Network Incident Managers (NIMs) instead of Train Services Delivery Managers (TSDMs).
- Initial and refresher training for Security Control Centre Operators was upgraded to improve emergency response communications.
- CCTV software was upgraded to include a centralised server-based analytics engine for alarm functionality, with ongoing development to reduce false alarms.
- Sydney Trains shared learnings with stakeholders, assessed emergency lighting improvements on Tangara Sets, reviewed personnel actions for alignment with procedures, and updated risk registers and procedures based on incident learnings.