Rail safety investigations & reports

Track worker fatally injured when struck by train W510, Clyde, New South Wales, on 18 June 2016

Investigation number:
RO-2016-008
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 2.19MB]
 

What happened

On 15 June 2016, Sydney Trains’ maintenance staff identified the 64 crossover points[1] (64 points) at Clyde yard as unfit for service and arranged to book the points out of use. 63B points on the Up Main line were also booked out of service to prevent rail traffic from operating over 64 points.

On 18 June 2016, Sydney Trains’ maintenance staff obtained a Track Occupancy Authority (TOA) to protect civil rectification work on 64 points. The protective limits of the TOA extended only to defined clearance points on either side of 64 points and did not include 63B points.

At approximately 0530, as the repairs neared completion, two members of a signal maintenance team (SMT) tasked to test and certify the operation of 64 and 63B points, arrived at Clyde yard. Both members of the team entered the danger zone near 63B points where train W510 struck and fatally injured one worker.

What the ATSB found

Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.

The Protection Officer (PO), who was part of the civil maintenance team, was aware of the signal team’s work tasks but did not consider these in his worksite protection arrangements. The PO had briefed the civil maintenance team, but did not brief the signal team, and the signal team did not seek a pre-work briefing before commencing work on-track. The PO was not provided with a briefing on the scope of the signal team work and did not provide protection at 63 points.

The signal team assumed their workplace was within the limits of the TOA and did not plan their own worksite protection. The signal team entered the danger zone unprotected and unaware of the approach of W510, and the Clyde Signaller did not recognise the signal team were in an unprotected area.

Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.

Although not contributing to the accident, the ATSB also found that Sydney Trains’ preference to keep the Up Main operational influenced the selection to use the clipped and locked 63B points to protect the worksite at 64 Points. The worksite protection method presented an increased risk in that if track workers inadvertently exited the worksite, they would be in the immediate vicinity of operational main line rail traffic.

The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.

Finally, the lack of use of train headlights at night and the absence of any supplementary lighting (such as beacons) may have increased the likelihood of a train driver not seeing workers in the danger zone.

What has been done as a result

Sydney Trains delivered on a number of safety actions and commitments following the incident.

Some of the direct actions to address the contributing factors to the incident were:

  • Review and validation of proposed worksite protection plans is required through Sydney Trains’ Corridor Safety Centre.
  • Increased numbers of rail safety coaches and mentors, with a required coaching session for all Protection Officers at least once per year.
  • Protection Officers are required to implement a form of worksite protection at least once every quarter to remain eligible to be re-certified as a Protection Officer, this activity is monitored by the Corridor Safety Centre.

Additionally, Sydney Trains established a Post Incident Assurance Group (PIAG) to respond to the incident. This group established key focus areas to promote the safety of workers and avoid future incidents. These areas included; Worksite protection, Culture, Planning for maintenance work and Safety critical communications.

The PIAG later established the Safety Focus Program, which included key initiatives:

  • Safety Focus Sessions
  • Safety Culture Program
  • Improvements to Protection Officer selection and training
  • Signal Key Switch Project
  • Safety Critical Communication Enterprise Wide Program
  • Maintenance Access Planning Project, and
  • ATRICS ASB.

Safety message

This accident highlights the importance of planning and integrating safety across the entire scope of work. It also highlights the importance of briefing all workers and all workers seeking a safety briefing about the worksite protection plans before work commences and when circumstances change.

__________

  1. 64 points was a set of crossover points, designed to allow rolling stock to cross over from one track to the other over the set of points. Crossover points have two ends (turnouts) that attach to the two rail lines. 64 points allowed trains to cross over from the Up storage siding to the Down through road (see Figure 7).
Download final report
[Download  PDF: 2.19MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

Safety Issues

Go to RO-2016-008-SI-01 - Go to RO-2016-008-SI-02 - Go to RO-2016-008-SI-03 - Go to RO-2016-008-SI-04 -

Work-planning process and multiple work groups

Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.

Safety issue details
Issue number: RO-2016-008-SI-01
Who it affects: Sydney Trains track work
Status: Partially addressed

Network Communications

The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.  

Safety issue details
Issue number: RO-2016-008-SI-02
Who it affects: Sydney Trains track work
Status: Adequately addressed

TOA limitations

The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen worksite protection method.

Safety issue details
Issue number: RO-2016-008-SI-03
Who it affects: Sydney Trains track work
Status: Partially addressed

Worksite protection pre-work briefing

The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.

Safety issue details
Issue number: RO-2016-008-SI-04
Who it affects: Sydney Trains track work
Status: Adequately addressed
General details
Date: 18 June 2016   Investigation status: Completed  
Time: 0608 AEST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Clyde   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 20 April 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Train details

Train details
Line operator Sydney Trains  
Train operator NSW Trains  
Train registration W510  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Minor  
Departure point Lithgow, New South Wales  
Destination Sydney Terminal, New South Wales  
Last update 20 April 2020