The Transport Safety Investigation Act 2003 forms the
basis of procedures followed by the Bureau.
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:
- The potential safety value that may be gained by conducting an
investigation;
- On board fatalities and/or serious passenger injuries;
- The public profile of the occurrence;
- The extent of resources available and projected to be
available; and, in the event of conflicting priorities,
- Any risks associated with not investigating; and
- The requirement under s21(2) of the TSI Act for the ATSB 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:
- Passenger operations;
- Freight and other commercial operations; and
- 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 Director and/or Deputy
Commissioner. 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 Commissioner, 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 Director level or above after discussion with the Director
and/or Commissioner. Any decision to discontinue an investigation
must be endorsed by the Commissioner.
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.
Railway Accident Investigation Guidelines for Railway Network
Owners, Railway Operators and Emergency Services Personnel