OTSI conducted this investigation in collaboration with the ATSB.

What happened

At approximately 0407 on 8 January 2021, freight train 5936, travelling in the up direction (towards Sydney) failed as a result of wheel slip, on the steep Cowan bank inside Boronia tunnel No. 3. To keep the up main line clear the train crew were directed by Sydney Trains network control to propel¹the train backwards into Hawkesbury River up refuge siding.

Network rules for propelling trains require crew to direct the movement from the rear of the train via radio communication with the driver. Due to the terrain, the assistant driver and a trainee were required to walk to the rear of the train on the adjacent down main line, as there was no alternate pathway beside the track. To protect these workers from passing trains, the driver of 5936 requested track protection from the Sydney Trains signaller. This protection was provided in the form of rail signals placed to stop to prevent a train from entering the section of track where the workers were walking.

On arrival at the rear of the train the two workers and the driver of 5936 proceeded to propel the train back towards Hawkesbury River up refuge siding in accordance with procedures, with the two workers walking in advance of the train on the adjacent down main line. During the propelling movement the workers observed the lights of an oncoming train on the down main line on which they were walking. The two workers told the driver of 5936 to stop the propelling movement and the train was brought to a stand. The workers jumped clear of the oncoming train onto the adjacent cess area, with one of the workers suffering an injury. A passenger train, 247B, passed the workers, travelling around train 5936 in the up direction towards Sydney on the down main line.

The driver of 5936 contacted the Sydney Trains signaller and requested an explanation about why a train had been permitted to run on the down main while there was meant to be a signal block in place to protect the workers.

The Sydney Trains signaller told the driver the signal block had been removed once the propelling movement started, due to the signaller mistakenly thinking the workers were clear of the down main line. The incident was not reported at the time by the Sydney Trains signaller. The incident was reported by the driver of 5936 to their control centre, but it was not acted on at the time. The incident came to notice when the trainee worker reported an injury resulting from jumping out of the way of train 247B.

What has been done as a result

Sydney Trains delivered the following actions following the occurrence:

Issued two Safe Tracks alerts to reinforce the requirements of Network Rule NTR 432, Protecting activities associated with in-service rail traffic, and related procedure NPR 750.
Issued an Operating Instruction 02/2022 to staff who manage this type of incident that deals specifically with propelling movements on Cowan Bank.
Adjusted the rail lubricators on Cowan Bank to provide optimum balance between lubrication of the rails while still permitting the train to retain traction on the rail surface.
Reintroduced Safety Refresher Training for signallers.
Delivered to all signallers an e-learning course on the use of NTR 432.
Use of NTR432 will be added to Signaller Competency assurance scenarios and the next annual round of Safety Refresher Training commencing during 2023.
Line managers have been required to focus safety engagements, undertaken with signallers, on ensuring signaller understanding of NTR 432. If non conformances are identified remedial coaching/training will be undertaken with the signaller.
From 18 November 2022 all Signallers have been instructed to report each use of NTR432 to their line manager and line managers have been instructed to submit an audio compliance request for all reported uses of NTR432 for a compliance review.
A communications cue card on use of NTR 432 for Signallers and Rail traffic crew was developed and distributed and is published on the RailSafe website.
A review of the network hazard of instance of worker in path of rail vehicle (protecting activities associated with in service rail traffic) is currently being undertaken.

Transport for NSW delivered the following action following the occurrence:

Assisted Sydney Trains through the provision of project support and vendor engagement for the design and development of safety refresher training.

Safety messages

To provide confidence that rules and procedures are being followed and that they are effective in managing relevant risks, rail operator assurance processes need to detect non-conformances.

Training and competence management regimes for rail safety workers need to provide relevant and meaningful content, such as scenario-based training, and site based network familiarisation, to allow workers to perform safely and effectively.

View the rail safety investigation report

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