Rail safety investigations in Australia

From 1 July 2019, report Category A rail occurrences directly to the Office of the National Rail Safety Regulator (ONRSR) on 1800 430 888 (24 hrs / 7 days).


The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory Agency. The ATSB is governed by a Commission and is entirely separate from State and Territory rail regulators, transport policy makers, and industry operators.

The ATSB’s function is to maintain and improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in:

  • independent investigation of transport accidents and other safety occurrences
  • safety data recording, analysis and research
  • fostering safety awareness, knowledge and action.

The ATSB conducts ‘no blame’ rail safety investigations in accordance with the Transport Safety Investigation Act 2003 (TSI Act). The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.

Does the ATSB investigate all rail accidents?

The ATSB investigates selectively, as do many equivalent organisations overseas. The aim is to concentrate ATSB’s resources on those investigations considered most likely to enhance rail safety. Because many accidents are repetitive in nature, investigating these in any detail may not be justified, given the ATSB’s limited resources. In such cases, the ATSB will not necessarily attend the scene, conduct an in-depth investigation or produce an extensive report.

When the ATSB investigates an accident or incident, investigators will seek to determine its circumstances, identify any safety issues, and encourage relevant safety action. The aim of all ATSB investigations is to prevent the occurrence of other accidents and incidents, rather than to assign blame or liability. This approach helps ensure the continued free flow of safety information for the purposes of improving safety in the future.

Reporting accidents and incidents

As required under the Transport Safety Investigation Regulations 2003 (TSI Regulations), train operating crew, rail and track owners and operators must report accidents and serious incidents (Category A occurrences) that occur as soon as practicable and by the quickest means possible. Telephone all Category A occurrences directly to ONRSR by calling 1800 430 888 (24 hrs/ 7 days).

For general advice or assistance on reporting requirements, please call the ATSB on the toll-free number 1800 011 034. If telephoning from outside Australia, please use +61 2 6230 4470.

The investigation

As soon as possible after receiving a report of a rail safety occurrence, the ATSB will decide what action to take. Depending on the type and severity this may be:

  • an on-site investigation carried out by investigators
  • a request for more information from an owner, employer or other party or
  • an entry of accident or incident details into the ATSB’s database.

The ATSB will advise relevant parties whether or not it will investigate. If there is to be an investigation, the ATSB will liaise with other parties, such as the designated accident site manager, to ensure that evidence is secured or recorded for further examination once ATSB investigators arrive on site. This is done to allow restoration of services as soon as possible.

The field phase of the investigation begins at the accident site. ATSB investigators photograph and record the evidence on the ground and later examine relevant documentation such as maintenance and train control records. They may visit and record or obtain evidence from other key locations. They may then arrange for rail vehicle components and other physical evidence to be transported to the ATSB’s Canberra office, or some other secure area, for further examination and testing. It is accepted protocol for ATSB investigators to seek information or assistance in a manner that encourages cooperation.

The ATSB will liaise with other parties who have an interest.

To reconstruct the sequence of events preceding the accident, ATSB investigators will, where possible, interview the operating crew, passengers where applicable, and other witnesses. This may also include supervisory and other management personnel. Investigators may ask for records relating to the training and experience of the operating crew and other key personnel, and may require company documents relating to the rail vehicle’s operation and other management and maintenance records considered pertinent to the occurrence.

Where fatalities are involved, investigators will sometimes need to interview the next of kin of the operating crew to understand the crew’s background or to examine professional documents or certificates kept at home. This is often an emotional time and investigators always contact the families before visiting. Such meetings allow the next of kin to meet the investigators personally and to question them about the handling and progress of the investigation.

Sensitive evidence collected in the course of an investigation is classified as restricted information under the provisions of the TSI Act. The Act contains provisions which prevent restricted information from being made freely available for purposes other than transport safety. Importantly, these provisions provide self-incrimination immunity for persons who are required to attend before the ATSB under powers of the TSI Act. Information provided under these circumstances cannot be used against the person in criminal or civil proceedings.   Information that is obtained in the course of the investigation including from directly involved parties may be disclosed in the ATSB report. The ATSB will remove information that directly identifies an individual (i.e. names and addresses). However, other indirect identifiers (i.e. times, dates and locations for the occurrence of incidents) will usually be disclosed in the interests of safety. In some situations an individual's position may need to be stated so that reports make sense and safety lessons can be learned by others.

ATSB reports

When an ATSB investigation is undertaken, a report is completed for public release. An investigation report can take many months to produce. It may be necessary to interview numerous individuals, cross-check evidence, examine suspect equipment and consult other technical experts. Often the safety factors identified by the investigation turn out to be very different from the explanations proposed in the media immediately after the event.

The ATSB will send a draft copy of the report to directly involved parties or their representatives. Those parties include individuals or organisations whose reputations may be adversely affected by the report. Under the TSI Act, recipients are required not to copy or disclose the contents of the draft report except for the purpose of providing comments to the ATSB on the draft report, or to take safety action in response to the report’s findings. They will normally have at least several weeks to respond before the report is finalised.

Directly involved individuals and organisations will receive an advance copy of the final report. Extra copies will be published either in printed form, or through the ATSB website www.atsb.gov.au on the day of the report’s public release.

ATSB investigation reports and most evidence collected during an investigation cannot be used in civil or criminal proceedings. ATSB investigation reports may be used in coronial inquiries for the purpose of improving safety.

Safety action

‘Safety action’ is the term used to describe any action taken by organisations and individuals in response to the safety issues that were identified during an investigation. The aim of any safety action is to prevent similar accidents and incidents.

The ATSB facilitates safety action by communicating the identified safety issues to the relevant organisations throughout the course of an investigation. The ATSB encourages proactive safety action and will acknowledge such action in its investigation reports.

Formal safety recommendations are normally issued when other attempts to facilitate safety action have been unsuccessful, and the risk level is considered by the ATSB to be either critical or significant. The ATSB has no legislative power to enforce its safety recommendations, but it can require a detailed response which may be made public, regarding the implementation of recommendations.

Coronial inquests or inquiries into rail safety occurrences

The relevant State or Territory Coroner may hold an inquest into a fatal rail accident. The Coronial inquest and the ATSB investigation are separate but they do interact.

ATSB investigators may be legally required to appear as expert witnesses. A date for an inquest or inquiry is determined by the Coroner.

The Coroner’s Office should be contacted on all matters relating to an inquest. Coronial services can also offer assistance and advice, and some Coronial jurisdictions provide grief counselling and other support for relatives by means of trained professionals.


During the investigation process the ATSB may collect personal information. The ATSB collects personal information for the purposes of investigating transport incidents and accidents. This is authorised by the TSI Act.

The ATSB will use this information for the purposes of the investigation and, subject to the restrictions in the TSI Act may disclose parts of the information to other parties for the purposes of the investigation. The disclosure will also be in accordance with the Australian Privacy Principles under the Privacy Act 1988.

Most personal information held by the ATSB is stored electronically such as on databases, shared drives or in emails, or on hard copy files. The information is held securely and access is limited to ATSB staff that need to access the material to perform their functions.

For more information on the ATSB investigation process visit www.atsb.gov.au where our privacy policy is also available, or ask for a copy of the policy to be provided to you.


Type: Corporate Brochure
Publication date: 28 August 2014
Last update 25 June 2019