Investigation Procedures

Decision Guidelines for Accident/Incident Categorisation

The ATSB is resourced each year to undertake a finite number of rail investigations on the Defined Interstate Rail Network (DIRN). It is acknowledged, however, that an occurrence with a large number of deaths (not including an occurrence that was primarily a road accident) would represent a major accident and supplementary funding may be required.

In categorising rail transport safety matters and selecting which of those the ATSB should investigate, the decision-makers must consider:

1. The potential safety value that may be gained by conducting an investigation;
2. On board fatalities and/or serious passenger injuries;
3. The public profile of the occurrence;
4. The extent of resources available and projected to be available; and, in the event of conflicting priorities,
5. Any risks associated with not investigating; and
6. The requirement under s21(2) of the TSI Act for the Executive Director to publish reasons (justification) for discontinuing an investigation where an investigation has already commenced.

The following broad hierarchy should also be taken into account when making the decision to initiate and categorise an investigation:

1. Passenger operations;
2. Freight and other commercial operations; and
3. Non-commercial operations.

The decision to investigate will also have regard as to whether, in the absence of an ATSB investigation, a credible safety investigation is likely.

In view of these considerations, initiation of a formal ATSB investigation can only be made at or above Team Leader level after discussion and agreement with the Deputy Director and/or Director and Executive Director. Each investigation will be categorised on a scale of 1 to 5 (see below).

Following the initial assessment of a rail transport safety matter a decision will be made whether or not to conduct a field investigation. Unless otherwise agreed by the Executive Director, all occurrences will initially be categorised at level 4. Subsequently an investigation may be upgraded or downgraded. The decision to upgrade (and commit extra resources) or to downgrade must be made at Deputy Director level or above after discussion with the Director and/or Executive Director. Any decision to discontinue an investigation must be endorsed by the Executive Director.

In relation to any ATSB investigation requested under state or NT legislation the Executive Director's approval to initiate the investigation is required. Where the ATSB reviews an investigation undertaken by another credible body (eg an independent investigation commissioned by a state rail regulator or the ARTC) and wishes to publish the report in the interests of future safety and permission to do so is given, such a report could be published by the Executive Director under the TSI Act with proper attribution.

The following guidance on the categorisation of rail transport safety matters is intended to serve as a suggested starting point based on initial information. This guidance is not intended to cover all possible scenarios but illustrates a broad range of typical events. It is expected that judgment will be required in order to categorise some events which do not neatly fit these categories or where the circumstances, potential safety value and available resources suggest that they should be assigned a different level.

Level 1

• An accident involving one or more trains resulting in large scale fatalities and serious injuries, property damage and intense public interest.

Level 2

• An accident involving one or more trains with 5 or more fatalities (except where it is primarily a road accident) plus serious injuries, property damage and intense public interest.

Level 3

• An accident involving one or more trains with less than 5 fatalities (except where it is primarily a road accident), serious injuries and property damage.
• An accident involving one or more trains with serious injuries and property damage (except where it is primarily a road accident) where there was a significant risk of fatalities or serious injuries (on-train or off-train), substantial property damage and a substantial commitment of investigative resources is likely to significantly mitigate the possibility of future accidents.
• A serious incident involving one or more trains and/or failure of a safety management system where there was a significant risk of multiple fatalities and serious injuries and a substantial commitment of investigative resources is likely to significantly mitigate future passenger train accidents.
• An accident involving one or more trains at an active level crossing where an investigation is likely to significantly mitigate future accidents.
• Occurrences indicating a trend that may involve serious safety deficiencies.

Level 4

• An accident involving one or more trains without fatalities or serious injuries and without substantial property damage where investigation is likely to contribute to mitigating future accidents.
• A serious incident involving one or more trains and/or failure of a safety management system where a limited commitment of investigative resources could contribute to mitigating future accidents.
• An accident involving one or more trains at a passive level crossing where a limited commitment of investigative resources could mitigate future accidents.
• Any other significant safety occurrence not included in the preceding categories.

Level 5

• An accident or serious incident where another competent body will be conducting an investigation and available resources do not allow for an ATSB investigation.
• An accident involving one or more trains without fatalities where the potential safety lessons do not, after initial review, justify the commitment of investigative resources within available funds. Data will be filed for statistical purposes.
• An accident involving one or more trains with off-train fatalities at a passive level crossing which is primarily a road accident.
• An accident or serious incident involving one or more trains and/or failure of a safety management system where the potential safety lessons do not, after initial review, justify the commitment of investigative resources. Data will be filed for statistical purposes.

Note: Fatalities do not include suicides or train surfers.

• Guideline for the first persons arriving at a railway accident site:

Railway Accident Investigation Guidelines for Railway Network Owners, Railway Operators and Emergency Services Personnel