Summary
Rail safety
investigations in Australia
The Australian Transport Safety Bureau (ATSB) is an independent
Commonwealth Government statutory Agency. The ATSB is governed by a
Commission and is entirely separate from State and Territory rail
regulators, transport policy makers, and industry operators.
The ATSB's function is to maintain and improve safety and public
confidence in the aviation, marine and rail modes of transport
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.
The ATSB conducts 'no blame' rail safety investigations in
accordance with the Transport Safety
Investigation Act 2003 (TSI Act). The Bureau does not
investigate for the purpose of taking administrative, regulatory or
criminal action.
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 those investigations considered most likely to enhance rail
safety. Because many accidents are repetitive in nature,
investigating these in any detail may not be justified, given the
Bureau's limited resources. In such cases, the ATSB will not
necessarily attend the scene, conduct an in-depth investigation or
produce an extensive report.
When the ATSB investigates an accident or incident,
investigators will seek to determine its circumstances, identify
any safety issues, and encourage relevant safety action. The aim of
all ATSB investigations is to 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 for the purposes of improving safety in the future.
Reporting
accidents and incidents
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 means possible. Noting that the
regulatory responsibility for rail is with the States and the
Northern Territory (NT), reports should be made to the relevant
State or the NT in accordance with established procedures. The ATSB
is then informed, so that it can determine whether or not an
investigation is needed. If reporting directly to the ATSB, call
the toll-free number 1800 011 034.
The
investigation
As soon as possible after receiving a report of a rail safety
occurrence, the ATSB will decide what action to take. Depending on
the type and severity this may be:
- an on-site investigation carried out by investigators;
- a request for more information from an owner, employer or other
party; or
- an entry of accident or incident details into the ATSB's
database.
The Bureau will advise relevant parties whether or not it will
investigate. If there is to be an investigation, the ATSB will
liaise with other parties, such as the designated accident site
manager, to ensure that evidence is secured or recorded for further
examination once ATSB investigators arrive on site. This is done to
allow restoration of services as soon as possible.
The field phase of the investigation begins at the accident
site. ATSB investigators 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. It is accepted protocol for ATSB
investigators to seek information or assistance in a manner that
encourages cooperation.
The Bureau will liaise with other parties who have an
interest.
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.
Investigators 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.
Sensitive evidence collected in the course of an investigation
is classified as restricted information under the provisions of the
TSI Act. The Act contains confidentiality provisions which prevent
restricted information from being made freely available for
purposes other than transport safety. Importantly, these provisions
provide self-incrimination immunity for persons who are required to
attend before the ATSB under powers of the TSI Act. Information
provided under these circumstances cannot be used against the
person in criminal or civil proceedings.
ATSB
reports
When an ATSB investigation is undertaken, a 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 safety factors identified by the
investigation turn out to be very different from the explanations
proposed in the media immediately after the event.
The ATSB will send a draft copy of the report to directly
involved parties or their representatives. Those parties include
individuals or organisations 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 individuals and organisations will receive an
advance copy of the final report. Extra copies will be published
either in printed form, or through the ATSB website
<www.atsb.gov.au> on the day of the report's public
release.
ATSB investigation reports and most evidence collected during an
investigation cannot be used in civil or criminal proceedings. ATSB
investigation reports may be used in coronial inquiries for the
purpose of improving safety.
Safety
action
'Safety action' is the term used to describe any action taken by
organisations and individuals in response to the safety issues that
were identified during an investigation. The aim of any safety
action is to prevent similar accidents and incidents.
The ATSB facilitates safety action by communicating the
identified safety issues to the relevant organisations throughout
the course of an investigation. The ATSB encourages proactive
safety action and will acknowledge such action in its investigation
reports.
Formal safety recommendations are normally issued when other
attempts to facilitate safety action have been unsuccessful, and
the risk level is considered by the ATSB to be either critical or
significant. The ATSB has no legislative power to enforce its
safety recommendations, but it can require a detailed response
which may be made public, regarding the implementation of
recommendations.
Coronial
inquests or inquiries into rail safety occurrences
The relevant State or Territory Coroner may hold an inquest into
a fatal rail accident. The Coronial inquest and the ATSB
investigation are separate but they do interact.
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. Coronial services can also offer assistance and
advice, and some Coronial jurisdictions provide grief counselling
and other support for relatives by means of trained
professionals.
State rail
investigations
The ATSB is sometimes 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.
| Type: |
Corporate Brochure |
| Publication Date: |
01/07/2009 |
