Rail safety investigations & reports

Safeworking irregularity involving Lookout Working, near Tempe, NSW on 31 July 2017

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

Final Report

Download final report
[Download  PDF: 1.24MB]

What happened

On 31 July 2017, a team of Sydney Trains’[1] infrastructure maintainers were conducting a series of inspections and measurements along the Up and Down[2] Illawarra Main and Up and Down Illawarra Local lines, Tempe. The workgroup were located between 746 points and 748 points when a passenger service 59-J travelling on the Down Illawarra Local line towards Tempe Station narrowly missed the workgroup as it passed their worksite. There were no injuries or damage.

What the ATSB found

The workgroup had relied on lookout working (LOW) as the method of worksite protection. Two workers were positioned as lookouts for oncoming trains; one trackside watching for the approach of Down trains, using track warning lights[3] (Down lookout), the other positioned at Tempe[4] Station footbridge watching for the approach of Up trains (Up lookout). The Down lookout had diverted his attention away from the warning lights to acknowledge an Up train. When he re-focussed on the warning lights, he realised a warning light for approaching Down trains had extinguished. He was not able to sound a warning to the workgroup and give them sufficient time to clear the danger zone to a safe location, before 59-J approached their location.

Additionally, the ATSB found the location of the worksite was considered unsuitable for LOW according to Sydney Trains’ Worksite Protection and Hazardous Locations Register (WPHLR).

What's been done as a result

On 12 November 2017, Sydney Trains made changes to NPR 711 Using Lookouts[5]. Instructions mandated that warning lights must not be used to provide warning of approaching rail traffic when using lookouts. Further, this instruction applied to all tracks in the Sydney Trains Network unless specifically exempted in the Network Local Appendices.

Sydney Trains is also reviewing the WPHLR with a view to simplifying the document by only including locations where LOW is specifically prohibited.

Safety message

Compared to the other worksite protection methods, Lookout Working (LOW) does not warn, or restrict trains from approaching, or entering a work location. Where practicable, rail transport operators (RTOs) must require track workers to continually re-assess the site risks, add/combine safety measures (like Automatic Track Warning System, or audible warning devices), or implement a higher form of protection.



  1. All trains, employees, roles, Network Rules, Network Procedures and maintenance responsibilities referred to in this report were under the control of Sydney Trains.
  2. Trains that travel away from Sydney are Down trains. The lines that carry them are Down lines. Trains that travel towards Sydney are Up trains. The lines that carry them are Up lines, e.g., ‘Up and Down Main’ Lines.
  3. A track warning light is defined as an illuminated white or orange warning light provided at locations where workers on track have a restricted view of approaching rail traffic. If rail traffic approaches, the light goes out, giving time for workers to move to, or remain in, a safe place (Network Rule NSG 604).
  4. The rail kilometrage for Tempe Station is 6.770 km by rail South of Central railway station. This was referenced from Network Local Appendices NLA 402.
  5. These changes were advertised on the RailSafe website and cited Safe Notice 1042-2017 (which outlined the specific change to NPR 711 Using Lookouts) and SafeTracks 3 November 2017 (which provided more information about the changes). Refer to www.railsafe.org.au/
Download final report
[Download  PDF: 1.24MB]

The occurrence


Safety analysis


Safety issues and actions

ATSB SafetyWatch

Safety Issues

Go to RO-2017-009-SI-01 - Go to RO-2017-009-SI-02 -

Use of warning lights

Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of Lookout Working (LOW). Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules.

Safety issue details
Issue number: RO-2017-009-SI-01
Who it affects: All track managers
Status: Adequately addressed

Single source of information for Lookout Working prohibition

Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to.

Safety issue details
Issue number: RO-2017-009-SI-02
Who it affects: All track managers
Status: Adequately addressed
General details
Date: 31 July 2017   Investigation status: Completed  
Time: 1000 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Tempe   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 25 July 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Sydney Trains  
Train operator Sydney Trains  
Train registration 59-J  
Type of operation Empty passenger service  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Circular Quay, NSW  
Destination Kingsgrove, NSW  
Last update 25 July 2019