Rail safety investigations & reports

Wrong running direction involving passenger train 165-S, Mt Druitt, NSW on 12 March 2015

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

At about 0513 on 12 March 2015, the driver of a Sydney Trains A-set passenger train operated the train in the wrong running direction from Mt Druitt station. Instead of travelling towards St Marys on the Down Suburban line, he drove 761 m in the opposite direction towards Blacktown. The driver only braked after a network control officer (NCO)[1] contacted him and told him to stop. At the time, only the driver and guard were on board.

At the same time, a Pacific National freight train was about four kilometres away and travelling towards the passenger train on the same line. The NCO also called the driver of the freight train and told him to stop. There were no injuries or damage as a result of this incident.

What the ATSB found

The ATSB found that a number of factors contributed to the driver losing awareness of the way the train was facing. It was likely the driver was:

  • confused about the direction due to changing ends seven times
  • distracted from the main task of driving as he had spent over 3 hours at Mt Druitt station performing other tasks before he started driving
  • at risk of making an error due to his high workload
  • feeling under pressure to move the train
  • impaired by fatigue due to being awake for over 21 hours and in the low range of the circadian sleep cycle.

Sydney Trains fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver.

The guard did not take any action to stop the train although the guard was aware that the train was running in the wrong direction.

What's been done as a result

Sydney Trains conducted an internal safety investigation and is implementing several safety actions in response to that internal report.

Safety message

Rail operators should ensure that adequate strategies exist to safeguard against fatigue impairment of train crew. It should also be noted that train crew have a responsibility to decline a shift if they feel that their performance may be affected by fatigue.

SydneyTrains A-set

 Sydney Trains A-set

Source: OTSI


  1. Network Control Officer - A Competent Worker who authorises, and may issue, Occupancy Authorities, and who manages rail traffic paths to ensure safe and efficient transit of rail traffic in the Network. (Sydney Trains - RailSafe Glossary)
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The occurrence


Safety analysis


Safety issues and actions

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Safety Issue

Go to RO-2015-005-SI-01 -

Fatigue management

Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver. 

Safety issue details
Issue number: RO-2015-005-SI-01
Who it affects: Sydney Trains
Status: Not addressed
General details
Date: 12 March 2015   Investigation status: Completed  
Time: 0513 ESDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Mt Druitt    
State: New South Wales    
Release date: 29 January 2016   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Sydney Trains  
Train operator Sydney Trains  
Train registration 165-S  
Type of operation Passenger  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Mt Druitt, NSW  
Last update 14 November 2018