The first persons arriving at a railway accident site can render valuable assistance to minimise injury and loss of life, reduce property loss through damage, and prevent loss of clues and evidence that can identify the factors that contributed to the accident.
Often police and emergency services and representatives of the railway network owner and/or railway operator are the first trained personnel to arrive at railway accident sites. In addition, supervisory officers coordinate response and recovery from locations off-site.
These guidelines have been prepared by the ATSB to assist these people to understand better the essential procedures and the requirements of the Transport Safety Investigation Act 2003 (TSI Act).
As soon as possible after receiving a report of a rail safety occurrence, the ATSB will advise relevant parties whether or not the ATSB will investigate. If there is to be an investigation, the ATSB will liaise with other parties such as the designated accident site coordinator to ensure that evidence is effectively secured or recorded, pending an ATSB investigator's arrival on site.
The ATSB undertakes to allow restoration of railway operations as soon as possible once the accident site has been examined and evidence collected.
Accident site coordination and security
When attending an accident site it is important to distinguish between control of the site in accordance with the TSI Act and the ‘hands on’ function of site control. The TSI Act and Regulations provide the ATSB with the means to ensure the protection of evidence on and off site, even when the ATSB is not in attendance. The ATSB acknowledges that the ‘hands on’ function of site control belongs, in the majority of circumstances, to the applicable rail infrastructure manager who will act in accordance with their accredited safety management system.
Once a site has been made safe by the emergency response agencies, and/or the track manager, a means of controlling access is agreed. The practise of preventing persons from entering an accident site is based on common sense, respect for casualties, protection of valuable and important equipment and the preservation of evidence in order to establish the factors that contributed to the accident and to prevent unnecessary exposure to hazards.
Clear and concise communication between the ATSB and the site manager/controller prior to the arrival of the ATSB is vital. Where a Protection Order has been issued by the ATSB, the Protection Order conditions and permission must be followed by the site controller.
The exchange of these forms is a routine function that serves the interests of all parties. The importance of clear and concise communication between the ATSB and the site manager/controller cannot be over-emphasised.
In particular, the ATSB regards the preservation of perishable evidence at an accident site as a matter of prime importance. This evidence should not be interfered with except in extraordinary circumstances such as rendering assistance to persons, animals or making a site safe.
Perishable evidence includes data recorder information, signalling equipment and position at time of accident, marks left on track and surrounds, wreckage location and so on. Should it be absolutely necessary to alter the state of vital / perishable evidence, then every effort should be made to record as accurately as possible the original position of this evidence at the time of the accident. Unless necessary for the preservation of life, or for safety purposes, wreckage should be left in situ to allow investigators to examine and methodically remove evidence.
Emergency services personnel are often the first at the accident scene. In this instance, they will be the initial site controllers / managers until their work is complete. During this period the following steps should be taken in order to preserve and record evidence.
With their permission:
1. Determine the perimeter of the accident site, all scattered wreckage, and any perishable evidence.
2. In conjunction with other emergency services personnel, manage access to the defined site.
3. Record as much perishable evidence as possible. If the site must be disturbed, before doing so, try to photograph, video, sketch, or record the original state of evidence moved or altered. DO NOT try to restore items of evidence to its original state unless the ATSB asks you to do so.
4. Record as much perishable evidence as possible, for example:
• signal indications and turnout positions at the time of the occurrence;
• marks left on rails;
• level crossing indications (active control operating or not at time of occurrence?);
• weather conditions including wind direction and speed, temperature, cloud cover;
• air brake equipment and gauges readings and apparent condition;
• temperature of brakes, wheels and bearings, and track;
• the position of other trains on adjacent lines;
• the position and registration number of motor vehicles in the vicinity of a level crossing.
5. Carefully record, as soon as possible, the positions from which injured persons of the accident were assisted or deceased persons were removed.
6. Take photographs beforehand if anything (eg, removal of deceased persons, the weather) is likely to obliterate or alter any marks on the track or on wreckage.
7. Secure the site and any of the transport vehicle’s equipment against loss or further damage.
8. Record the names, addresses, contact details particularly telephone numbers, and intended movements of any witnesses.
Make sure that the individual concerned is aware that the information is being collected for a transport safety investigation and that it will be passed on to the ATSB for this purpose. Seek their consent if possible.
The names and addresses of witnesses should be noted and the list passed on to the ATSB on their arrival at the accident site. Preliminary eyewitness statements detailing first reactions can be of great value to investigators. Such statements will generally be untainted by reflection, rumour, or exposure to the news media.
Event and data recorders
Event and data recorders provide vital, but perishable, evidence of the moments leading up to the accident. Event and data recorders may be fitted to:
• locomotive systems;
• signalling equipment;
• train control centres.
They may also take the form of:
• security monitoring (CCTV);
• on-board passenger security monitoring (CCTV);
• level crossing circuitry data;
• wheel and bearing track-side monitors;
• in-motion wagon weighing.
Unless arranged by the ATSB, event and data recorders MUST NOT be disturbed or downloaded unless there is a danger of loss. However, every effort must be made to isolate or prevent valuable data from being lost after the accident.
Recovery of the site
The ATSB is very conscious of the need to restore the track and resume services as quickly as possible after a rail accident. ATSB investigators, however, have a duty to ensure that any accident they attend is investigated thoroughly. In any accident the ATSB must be satisfied that the evidence collected is as complete as possible.
Soon after the ATSB receives notification of a rail accident the track owner and train operator will be advised if the ATSB requires control of the site.
Although a ‘Protection Order’ may be issued under the TSI Act for pieces of equipment, or part or the entire accident site, permission under the Protection Order may allow site recovery. This will be assessed on a case-by-case basis. To expedite the recovery process, the ATSB may release sections of the site as the investigation progresses. If any fatalities have resulted from a rail accident, the ATSB will coordinate with the relevant coroner regarding the release of wreckage etc.
If the ATSB needs all or part of the wreckage for off-site examination, the ATSB will work with the track owner or train operator to arrange for recovery.
Coordinating with police inquiries
Where the accident investigation involves police inquiries (e.g., for the information of the coroner or a criminal investigation), the ATSB will assist where possible, within the constraints of the TSI Act. However, the ATSB investigation and any police investigation are entirely separate. The ATSB does not investigate for the purpose of apportioning blame or determining liability.
If early evidence suggests the accident was the result of a serious criminal act, the police would normally direct the investigation and the ATSB would not investigate.