Site protection failings lead to track worker safety breach

Incident location – Tempe, NSW. Source: ATSB

On the morning of 31 July 2017, a team of four Sydney Trains infrastructure maintainers was conducting a series of regular inspection and measurements at points along the Illawarra Main and Local lines at Tempe in Sydney’s inner west.

Two of the workers were acting as an inspection team, entering the danger zone (the area within three metres horizontally from the nearest rail) and accessing the track.

The other two workers acted as lookouts, using the Lookout Working method, which consists of rules for working in the danger zone using lookouts, and requires all workers and equipment to be completely within a safe place a minimum of 10 seconds before rail traffic passes their location.

Conducting work on or near railway track can be dangerous if safeworking rules and procedures have not been correctly implemented.

At approximately 10.00am, an empty passenger train was travelling on the Illawarra Local line when the driver observed the work group in the danger zone. He applied the brakes and blew the horn, and the workers began to move off the line towards a safe place to the side of the track. A review of the CCTV footage from the train showed that the workers had not yet reached a safe place when the train passed their location, approximately seven seconds after the train first observed them. There were no injuries or damage.

The investigation, conducted on behalf of the ATSB by NSW’s Office of Transport Safety Investigations (OTSI), found issues with the workgroup’s reliance on Lookout Working for worksite protection. Each lookout had been positioned to watch in different directions – one monitoring for Up trains, the other for Down trains. This incident occurred when the Down lookout had turned away to monitor the situation with an approaching Up train (which did not pose an immediate risk to the work group), and then turned back to find that a Down train was also approaching. He was not able to sound the warning to the work group and give them sufficient time to clear the danger zone to a safe location before the train neared their location.

Compared to other worksite protection methods, Lookout Working does not warn, or restrict trains from approaching, or entering a work location. The investigation found that Lookout Working had been implemented in an area deemed not suitable on the Sydney Trains rail network.

Additionally, there was not a clear understanding within the work group of various elements of the Lookout Working system, resulting in reassessments not being made, the Up lookout being posted in an inappropriate area, and a misunderstanding of what constituted a safe place.

The ATSB safety message from this investigation stresses that where practical, rail transport operators must require track workers to continually re-assess the site risks, add and or combine safety measures (like an Automatic Track Warning System, or audible warning devices), or implement a higher form of protection.

Read the investigation report: RO-2017-009: Safeworking irregularity involving Lookout Working, near Tempe, NSW on 31 July 2017

Last update 13 August 2019