Rail safety investigations & reports

Collision between track worker and passenger train at Guildford, Western Australia on 10 February 2015

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

On 10 February 2015, a Public Transport Authority (PTA) maintenance crew commenced work at Meadow Street, Guildford, Western Australia. The crew’s assigned tasks included maintaining the pedestrian gates adjacent to the level crossing.

At about 1035 one of the track workers was struck by a Perth-bound suburban passenger train. The track worker sustained fatal injuries.

What the ATSB found

The ATSB investigation found that the PTA maintenance workers had not implemented any form of track worker protection at the work site. This was partially due to the PTA not having documented instructions specifying the level of protection required, preferring that track workers make their own assessment based on their knowledge of the Network Rules. The ATSB found that, under these arrangements, track workers could make an incorrect assessment, placing themselves at a greater risk of being struck by a train.

A review of the safeworking training provided to the track workers found that the training material did provide a suitable level of safe-working knowledge.

Following the occurrence, the toxicology report on the deceased track worker identified the presence of amphetamine and methamphetamine; methamphetamine being a prescribed drug under the Rail Safety Regulations 2011. The use of stimulants such as methamphetamine is associated with a range of neurocognitive effects in humans that may affect performance.

The ATSB found that in this instance, the presence of a prescribed drug within the worker’s system appeared to be a relatively isolated case. An examination of the company’s drug and alcohol policy / procedures found them to be generally effective in managing drugs and alcohol in the workplace.

What's been done as a result

The PTA issued a safety alert following the incident to highlight the importance of implementing the correct level of track worker protection. The subsequent introduction of new safeworking rules, track access accreditation levels and training further supported this.

Further, the PTA has created the role of Workplace trainer and assessor with the task of ensuring track workers comply with the network rules by way of competency-based assessments. Implementation of a new track access accreditation system, with improved training and job mentoring, has also commenced.

Safety message

This incident strongly emphasises the need for rail transport operators to provide clear and concise work instructions to employees working within the railway corridor. It also highlights the potential for recreational and other drug use to impair performance and affect workplace safety.

Meadow Street pedestrian gate
Meadow St pedestrian gate
Source: ATSB

Download Final Report
[Download  PDF: 1.87MB]

The occurrence



Safety issues and actions


Download Preliminary report
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Preliminary report released 7 September 2015

On the morning of 10 February 2015, a track worker was struck by a Perth bound suburban passenger train at the Meadow Street level crossing at Guildford, WA.  The track worker sustained fatal injuries.

Download Preliminary report
[Download  PDF: 570KB]

The occurrence


Safety analysis

Ongoing investigations

Preliminary findings

Safety issues and actions

Sources and submissions

Safety Issue

Go to RO-2015-002-SI-01 -

Documented instructions

The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.

Safety issue details
Issue number: RO-2015-002-SI-01
Who it affects: All owners, operators and maintainers of railway infrastructure.
Status: Adequately addressed
General details
Date: 10 February 2015   Investigation status: Completed  
Time: 1035 WST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Guildford    
State: Western Australia    
Release date: 10 March 2016   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Train details

Train details
Line operator Public Transport Authority of Western Australia  
Train operator Public Transport Authority of Western Australia  
Train registration AEA239/AEB339  
Type of operation Metropolitan Public Transport  
Sector Passenger - metropolitan  
Damage to train Minor  
Destination Perth, WA  
Last update 03 April 2020