Final Report


What happened

At 1137 on 22 May 2014, NSW Trains XPT passenger service NT33 departed Paterson towards Kilbride when the driver observed a bus at the Mirari road level crossing and people walking on the track ahead. The driver immediately made an emergency brake application and brought the train to a stand approximately 80 m short of the people.

There were no reported injuries as a result of the incident.

What the ATSB found

A disabled coal train SF630 had initially delayed NSW Trains’ passenger service V938. A decision was made to evacuate V938 and provide the passengers with alternative road transport.

The train crew of V938 did not comply with the Australian Rail Track Corporation (ARTC) network rules when detraining passengers from their train and unknowingly placed the passengers in the path of NT33.

The NSW Trains procedure for detrainment did not preference the option of moving to a designated platform when available and would have required approval from the network owner ARTC. This option was also absent from ARTC’s Network Rules and Procedures.

Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority. This misunderstanding of roles, responsibilities and limits of authority by operational employees likely contributed to inadequate communication between critical safe working positions.

What's been done as a result

NSW Trains has informed the ATSB they had commenced an immediate review of procedures for detraining passengers when a train is not at a designated station. It has also informed the ATSB that the procedures had also been amended to clarify how passenger safety, their wellbeing and track protection will be managed when detraining.

Safety message

This incident illustrates the importance for train crews to strictly adhere to recognised detraining and track protection procedures when transferring passengers from a stranded train to a safe place.

It is essential that train crew and network control implement an appropriate level of protection and confirm that the protection is in place before detraining passengers.

When the option is available, preference should be given to detraining at a recognised platform before electing to detrain passengers into the rail corridor.

Operators must confirm and ensure roles, responsibilities and limits of authority are clearly understood during organisational change.


Mirari Road level crossing Kilbride
Mirari Road level crossing Kilbride

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions