This is a summary of recently completed rail investigations by the Office of Transport Safety Investigations (OTSI) and highlights ongoing rail investigations.
OTSI is empowered under the Transport Administration Act 1988 (rail, bus & ferry) in accordance with the Passenger Transport Act 1990 and Marine Safety Act 1998. We also investigate rail incidents using the Transport Investigation Act 2003 (Cth) under a Collaboration Agreement with the Australian Transport Safety Bureau (ATSB).
The Chief Investigator initiates investigations and determines how they are conducted. Final reports tabled by the Minister in NSW Parliament. We conduct no blame investigations to raise industry awareness of safety lessons that can be applied to support improved track worker safety.
Safety messages from recently completed investigations
Runaway and derailment of loaded grain train, Dombarton
Incident date: 15 December 2020
Key safety messages
- Conduct proper risk assessment to identify critical operational requirements for safely running trains down steep sections of track.
- Ensure key controls which prevent runaways have greater error tolerability on high-risk sections of track (such as steep descents).
- Load trains within safe limits; avoid overburdened individual wagons.
- Verify sufficient braking capacity before departure and monitor performance throughout the journey.
- Follow established procedures and report any concerns about loading or braking issues.
Derailment of freight train, Nana Glen
Incident date: 25 February 2021
Key safety messages
- Ensure effective systems to identify, assess and manage the risks so that trains are prevented from entering sections where the design of the infrastructure has been exceeded.
- Provide guidance and operational procedures to enable consistent response to conditions that may affect the integrity and operational safety of rail infrastructure.
- Develop guidance for train crew to respond to and report extreme wet weather events or floodwater in the rail corridor.
Report on Rail Worksite Protection in NSW, Picton
Incident date: 16 August 2022
Key safety messages
- Rail infrastructure managers should ensure effective systems are in place to manage risks and ensure track protection workers are given sufficient time to appropriately plan protection works and are supported with effective systems to positively identify rail traffic as clear of a worksite
- Contract managers should assure themselves that risks are being managed by the service provider in line with expectations.
This report, released in December 2023, is the first part of a systemic investigation into rail worksite protection in NSW. The second report (due in Q2 2024) covers an incident at Cowan on 13 January 2023. The third report will cover the entire systemic investigation.
Ongoing investigations
Collision and derailment between trains 1150 and T296, Port Botany
Incident date: 13 January 2023
What happened
On the morning of 13 January 2023, two trains collided and derailed during a propelling movement. Both trains derailed with the rear of one coming to a rest against a nearby building. There was significant damage to both trains and local rail infrastructure.
Fatality on locomotive of train 4MB9, Cullerin
Incident date: 25 August 2022
What happened
On the afternoon of 25 August 2022, two locomotives were hauling a containerised freight train north of Yass, NSW, en route to Bromelton, Queensland. For reasons not yet determined, while the train was still moving the driver left the driving cabin. After an extended period, the driver's assistant stopped the train and left the driving cabin to ascertain the driver's whereabouts. They found the driver unresponsive on the locomotive footplate, having sustained fatal injuries.
Derailment of freight train 2BS4, Kyogle
Incident date: 31 May 2022
What happened
At approximately 0102 on 31 May 2022, freight train 2BS4, derailed near Kyogle. The train was travelling towards Sydney on a single line section of the North Coast line at the time of the derailment. Eleven wagons derailed and a significant amount of damage to wagons and track infrastructure occurred.
Rail worksite protection in NSW systemic investigation
Incident date: April 2022
What happened
Over the years, OTSI has investigated numerous rail worksite protection incidents and accidents, including fatal events. After consideration and analysis of investigation findings, incident notification data and other sources of information, OTSI determined that a systemic investigation in rail worksite protection NSW was warranted.
Scope of investigation
The investigation is continuing and will include
- what controls Rail Infrastructure Managers have in place to manage worksite protection
- common causal pathways to worksite protection incidents
- patterns of incidents specifically related to particular planning phases, or types of protection
- technology controls proposed, researched, trialed, or currently being used to improve worksite protection in NSW and elsewhere
- examination of whether there are common barriers to the adoption of higher order controls that minimise or eliminate workers on track including enabler to support uptake
- actions taken to improve worksite protection in general in NSW and elsewhere
- how others, both interstate and internationally are managing worksite protection and in particular introduction of higher order controls
- the conduct of risk assessments and how they address worksite protection risks and controls.
The worksite protection in NSW systemic investigation will be the third report. The first report was on an August 2022 incident at Picton, released in December 2023. The second report, focusing on an incident at Cowan on 13 January 2023 is expected to be released in Q2 2024.
Collision between banking locomotives and grain train 5446, Werris Creek
Incident date: 6 January 2022
What happened
Three banking locomotives were attached to the rear of a grain train at Werris Creek in preparation for banking operations up the heavy grade between Chillcotts Creek and Ardglen. Shortly after departure from Werris Creek, the three banking locomotives separated from the rear of the grain train. As a result, the grain train's brakes automatically applied and the train came to a stop. The banking locomotives collided with the rear of the stationary train. One driver on the banking locomotives sustained minor injuries.
Sydney light rail vehicles underframe structural fractures
Incident date: 27 October 2021
What happened
On 30 September 2021 the Sydney light rail vehicle maintainer identified some fractures of Urbos LRVs operating on Sydney’s Inner West light rail network. The fractures were identified around the LRV’s bogie rotational bump stops.
Collision between passenger train C012 and a car, Kembla Grange
Incident date: 20 October 2021
What happened
A passenger service collided with an abandoned car on the rail line near an active level crossing at Kembla Grange at approximately 0410 on 20 October 2021. The first car of the train derailed and tipped onto its side as a result of the collision.