The safety of track workers is an ongoing challenge for the rail industry. ‘No-blame’ investigations into safeworking incidents offer valuable insights on the effectiveness of existing worksite protection methods and can also provide advice on what measures might be adopted in future to prevent incidents and near misses on track.
This summary of ten selected investigations conducted by the Office of Transport Safety Investigations (OTSI), either under NSW legislation or on behalf of the Australian Transport Safety Bureau (ATSB), is designed to raise industry awareness of safety lessons that can be applied to support improved track worker safety.
The NSW rail network relies heavily on administrative controls and the application of rules, procedures and communication protocols to protect track workers. OTSI/ATSB investigations have identified a lack of compliance—through human error—with rules, procedures and protocols, as contributing to a large number of causal factors in safety incidents.
Several investigations have also identified contributing factors such as a lack of training and knowledge, accepted norms of risk-taking, and inadequate compliance assurance.
Given the challenges involved in eliminating human error, reducing the need for workers to be on track through greater use of technology and engineering controls will be a focus for improving track worker safety in future.
Incorrect placement of worksite protection and near hit with worker, Otford
Incident date: 29 June 2021
Key safety messages
- Protection Officers (including contractors) and other rail safety workers require effective induction in their work location to reduce the risk of becoming disoriented.
- Safeworking training should cover relevant infrastructure that can help workers to correctly orient themselves in the rail corridor.
- The Network Rules and Procedures for Track Occupancy Authority should provide for location assurance for workers placing or removing protection.
Incorrect placement of worksite protection, Zig Zag
Incident date: 15 September 2020
Key safety messages
- The safeworking training and assessment process should adequately address skills associated with spatial orientation in the rail corridor.
- The possession management process must adequately equip rail safety workers with the information they need to fulfil their tasks safely and effectively.
- Rail infrastructure managers need a uniform approach for protecting workers when placing or removing protection in a local possession authority.
Near hit with rail worker by passenger train 283D, Dora Creek
Incident date: 9 May 2020
Key safety messages
- Network Rules and Procedures for safeworking on railways have been developed to give direction and instruction to workers in how to safely manage work on track. When practices develop that deviate from the established procedures, care needs to be exercised to ensure these practices do not introduce unintended risk.
- Rail safeworking practices should only be implemented as approved by the rail infrastructure manager.
Near hit with workers on track using Absolute Signal Blocking, Westmead
Incident date: 15 October 2019
Key safety messages
- Railway safeworking rules should be developed so that the desired outcomes are supported by suitable procedures.
- Signallers are safety critical workers who carry out work vital to the safe performance of the rail network. They require supervision and should be subject to suitable management arrangements to ensure compliance with relevant work instructions and requirements.
Safeworking irregularity involving crew of freight train 4WM2, Waterfall
Incident date: 21 August 2019
Key safety messages
- Rail infrastructure managers and rail transport operators need to ensure safety critical communication is conducted in accordance with network rules.
- Network controllers should consider the potential dangers train crews are exposed to before requiring them to enter the danger zone.
- Workers must ensure they have appropriate safeworking protection in place before entering the danger zone and are protected from rail traffic.
- Workers must also ensure that rest periods are utilised to manage non-work-related fatigue.
Near miss with maintenance worker on Skitube Alpine Railway, Bullocks Flat
Incident date: 3 July 2019
Key safety messages
- Workers must ensure they are protected and follow safety procedures before entering the danger zone or when interacting with trains.
- Systems should identify when conflicting activities take place that increase the risk to workers.
- Organisations should assess their risk controls for adequacy in protecting workers, and where required consider additional lines of defence.
Near miss with rail safety worker by trains 89-K and 88-C, near Redfern
Incident date: 8 September 2018
Key safety messages
- Planning and controlling worksites within the rail corridor is critical, especially when working within tunnels and at platforms where access can be from multiple locations.
- Workers must ensure they receive the required safety briefing prior to undertaking work or entering a new work area, and seek further information if required prior to starting work.
- Workers should stop and find a safe place in the event they become lost or separated from their work group.
Track worker fatally injured when struck by train W510, Clyde
Incident date: 18 June 2016
Key safety messages
- Where multiple teams are involved, the operator’s work planning must assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.
- All workers must be briefed and all workers seeking a safety briefing about the worksite protection plans before work commences and when circumstances change.
- Network communications must be carried out in accordance with the principles underpinning the network rules.
Track worker fatality, Kogarah
Incident date: 13 April 2010
Key safety messages
- Rail infrastructure managers should implement regular training for area controllers using simulations and drills to demonstrate competence in the use of the emergency facilities.
- Rail infrastructure managers should undertake random audits on the implementation of worksite protection across the network to confirm conformance with the relevant policies, rules and procedures.
- Employers of track workers should conduct random monitoring of the implementation of worksite protection arrangements and adherence to network communications protocols by their workers.
Fatal injuring of two rail maintenance workers, Singleton
Incident date: 16 July 2007
Key safety messages
- Worksite protection arrangements must be documented.
- The role of a Protection Officer must be performed by someone with the requisite qualifications.
- Information concerning the presence of workers on the track must be passed by Network Controllers to drivers operating rolling stock on the same track.