Rail Safety Investigation Report - Rail Worksite Protection in NSW - Report 2 Cowan, 11 January 2023

What happened

On 11 January 2023, Sydney Trains’ Engineering and Maintenance Branch prepared to conduct track work on the Up (travel towards Sydney) and Down (travel away from Sydney) Main North lines between Cowan and Hawkesbury River. Two planned track possessions, known as Local Possession Authorities (LPAs), were to take place.

After receiving verbal assurance from the Signaller Hornsby North (SHN) in the Homebush Control Centre (HCC), Sydney Trains’ Train Service Delivery Manager (TSDM) in the Rail Operations Centre (ROC) authorised both LPAs at the same time.

Four minutes after the authorisation, NSW Trains electric passenger service N191 traversed the Up Main North line in the Down direction from Cowan to Hawkesbury River. The SHN had authorised N191 to enter a section of track that was meant to be protected by LPA 1 but wasn’t protected. There were no injuries or damage to assets, but this incident posed a potential risk of a passenger train striking workers or equipment.

What we found

The investigation made several key observations of factors which contributed to the incident, including:

• misinterpretation of safety rules
• inattention or distraction (possibly due to unauthorised use of electronic devices)
• lack of familiarity with LPA arrangements
• simultaneously issuing multiple LPAs with differing protection requirements increasing the likelihood of critical information or errors being missed.

Stakeholder actions taken during the investigation

The following are safety actions undertaken by Sydney Trains:

• Contacted Transport for NSW (TfNSW) IT to develop a better management solution for computers on signaller workstations including monitoring of their use; limit the accessibility of non-work related activities such as games and the internet, and restrict internet access of safety critical workers in Signal Box Operations.
• Conducted a root cause analysis workshop, confirming that the Network Rules require railway track signals and possession limit markers for all LPAs. This information was communicated to relevant staff and followed up by conducting targeted assurance activities to ensure correct implementation.
• Engaged a human factors professional to explore the need for TSDMs or peers to validate a signaller’s work – they determined this was not practical.

Recommendations/safety actions

This report contains observations, not recommendations.

The Cowan investigation is part of a systemic investigation into worksite protection in NSW to be delivered in early to mid-2025. It follows the release of a report in December 2023 on a worksite protection incident at Picton in 2022.