Summary
The Australian Transport Safety Bureau (ATSB) is an operationally independent
body within the Australian Government Department of Infrastructure, Transport, Regional Development and Local Government
and is Australia’s prime agency for transport safety investigations. The
bureau is entirely separate from transport regulators and service providers. The
ATSB’s objective is safe transport. Its mission is to maintain and improve
transport safety and public confidence through excellence in:
- independent investigation of transport accidents and other safety occurrences;
- safety data recording, analysis and research; and
- fostering safety awareness, knowledge and action.
With the passage of the Transport Safety Investigation Act 2003 (TSI
Act), from 1 July 2003 the Commonwealth, through the ATSB, has broad powers
to investigate rail accidents and serious incidents on the Defined Interstate
Rail Network (DIRN). The bureau may also investigate intrastate rail accidents
and serious incidents when requested by states or the Northern Territory.
Does the ATSB investigate all rail accidents on the DIRN?
The bureau investigates selectively, as do many equivalent organisations overseas.
The aim is to concentrate ATSB’s resources on in-depth investigations considered
most likely to enhance rail safety.
When the ATSB investigates an accident or serious incident, investigators will
seek to determine its circumstances and make any necessary safety recommendations.
The ATSB’s role is to help prevent the occurrence of other accidents and
incidents rather than to assign blame or liability. This approach helps ensure
the continued free flow of safety information. As the ATSB is not a regulatory
authority it cannot enforce its safety recommendations. It relies on its reputation
and wide dissemination of findings for recommendations to be adopted.
When a rail accident or serious incident occurs
As required under the Transport Safety Investigation Regulations 2003 (TSI Regulations),
train operating crew, rail and track owners and operators must report accidents
and serious incidents (Immediately Reportable Matters) that occur on the DIRN
as soon as practicable and by the quickest possible means to the relevant state
or territory rail safety regulator in accordance with established procedures,
or also to the ATSB. Where a rail safety regulator, as a Nominated Official under
the TSI Regulations, receives a report, the regulator will report in turn to the
ATSB. Reports to the ATSB can be made on 1800 011 034.
As soon as possible after receiving a report of a rail safety occurrence, the
Bureau will advise relevant parties whether or not the ATSB will investigate.
If so, the ATSB will liaise with other parties such as the designated accident
site manager to ensure that evidence is secured or recorded pending further examination
before ATSB investigators arrive on site in order to allow restoration of services
as soon as possible.
The ATSB will invite the following parties, as a minimum, to participate as a
team member of an ATSB rail safety investigation:
- An officer of the rail safety regulator from the state/territory in whose
jurisdiction the relevant occurrence happened;
- A representative from the operator/s whose rail vehicles were involved
in the occurrence; and
- A representative from the track access provider on whose track the relevant
occurrence happened.
Participation will be to the extent necessary to enable all the underlying factors
of a rail safety occurrence to be determined in accordance with the TSI Act.
All participants will be required to abide by ATSB investigation protocols and
directions, sign a participant agreement form covering confidentiality undertakings,
and must be prepared to maintain an ongoing commitment to the investigation including
both the field and post-field phases of the investigation.
Participants must declare any conflicts of interest or perceived conflicts of
interest that they may have in relation to an investigation. The ATSB may exercise
discretion to alter the arrangements involving the team member’s participation
in the investigation or to exclude the officer from the investigation if necessary.
In addition, individuals being interviewed may decline to have participants other
than ATSB investigation personnel present at the interview if this would make
them feel more comfortable.
Investigation powers
The ATSB is only concerned with future safety. Therefore, the powers contained
within the TSI Act cannot be used against individuals or companies for any role
they may have played in a transport safety occurrence. Investigators may wish
to interview persons directly or indirectly involved with an accident or serious
incident or to remove and retain relevant documentation and physical evidence
for further examination and analysis. Additionally, investigators may need to
enter premises including accident sites, vehicles, buildings and other places
to complete their inquiries.
Consistent with international practices, it is accepted protocol for ATSB investigators
to seek to obtain information or assistance in a manner that encourages cooperation.
However, where multiple and conflicting interests are associated with the subject
matter of an investigation, the powers to access information must match the potential
incentive to deliberately tamper with or destroy evidence or to withhold or provide
false information. Where such powers are exercised, a number of checks and balances
in the TSI Act ensure that those powers are strictly controlled.
A comprehensive regime of protection for sensitive safety information is provided
for in the TSI Act to support the principle that such information is to be used
for safety purposes only. Importantly, this includes self-incrimination immunity
for persons who are required to attend before the Executive Director under section
32. Information provided to the Executive Director in those circumstances cannot
be used against the person in criminal or civil proceedings.
The investigation
The field phase of the investigation begins at the accident site. ATSB investigators
will photograph and record the evidence on the ground and later examine relevant
documentation such as maintenance and train control records. They may visit and
record or obtain evidence from other key locations. They may then arrange for
rail vehicle components and other physical evidence to be transported to the Bureau’s
Canberra office, or some other secure area, for further examination and testing.
To reconstruct the sequence of events preceding the accident, ATSB investigators
will, where possible, interview the operating crew, passengers where applicable,
and other witnesses. This may also include supervisory and other management personnel.
They may ask for records relating to the training and experience of the operating
crew and other key personnel, and may require company documents relating to the
rail vehicle’s operation and other management and maintenance records considered
pertinent to the occurrence.
Where fatalities are involved, investigators will sometimes need to interview
the next of kin of the operating crew to understand the crew’s background
or to examine professional documents or certificates kept at home. This is often
an emotional time and investigators always contact the families before visiting.
Such meetings allow the next of kin to meet the investigators personally and to
question them about the handling and progress of the investigation.
The investigators will present their initial findings to ATSB management who will
then decide how the investigation should proceed and what form the report should
take. The ATSB is committed to keeping the next of kin informed about the known
facts of the investigation. Where appropriate and possible, it will privately
brief the next of kin and immediate family before the final report is publicly
released.
Rail safety reports
When an investigation of a rail safety accident or serious incident is undertaken,
an investigation report is completed for public release. An investigation report
can take many months to produce. It may be necessary to interview numerous individuals,
cross-check evidence, examine suspect equipment and consult other technical experts.
Often the contributing factors identified by the investigation turn out to be
very different from the explanations proposed in the media immediately after the
event.
The report will not seek to apportion blame. As required under the TSI Act, no
one will be able to use the report for civil or criminal proceedings. If appropriate,
the report will include safety recommendations. The ATSB will send a draft copy
of the report to directly involved parties or their representatives. These will
include individuals or organisations who were directly involved in the circumstances
surrounding the occurrence or whose reputations may be adversely affected by the
report.
Under the TSI Act, recipients are required not to copy or disclose the contents
of the draft report except for the purpose of providing comments to the ATSB on
the draft report or to take safety action in response to the report’s findings.
They will normally have at least several weeks to respond before the report is
finalised.
Directly involved parties will receive a printed copy of the final report.
The final report is also distributed to all state and territory rail safety
regulators, interstate operators, international investigation agencies and other
relevant parties. Extra copies will be published either in printed form or through
the ATSB website www.atsb.gov.au
Coronial inquests or inquiries into rail safety occurrences
The state or territory coroner may hold an inquest into a fatal rail accident.
The coronial investigation and the ATSB investigation are complementary.
ATSB investigators may be legally required to appear as expert witnesses. A date
for an inquest or inquiry is determined by the coroner.
The Coroner’s Office should be contacted on all matters relating to an inquest
or inquiry. Coronial services can also offer face to face assistance and advice,
and some Coronial jurisdictions provide grief counselling and other support by
means of trained professionals.
State rail investigations
The ATSB is periodically invited by State authorities to investigate serious rail
accidents and incidents on intrastate rail systems. If the ATSB is invited to
do so and resources are available, it will carefully consider a request for such
assistance.
Download Complete Document: Rail_Safety_in_Aust [ PDF: 328Kb]
Type: Corporate Brochure
Publication Date: 06/06/08
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