Rail safety investigations & reports

Safeworking irregularity involving Track Work Authority, at Blackheath, New South Wales, on 2 September 2018

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

Final Report

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[Download  PDF: 630KB]

What happened

On 2 September 2018, a Sydney Trains workgroup conducting a track inspection had to move to a safe location beside the track as a NSW Trains’ passenger train, W532, approached. The incident occurred in a worksite protected by a Track Work Authority, in a section of track between Blackheath and Medlow Bath stations on the Main West line.

The maintenance work group began working on a section of line that passenger train W532 was travelling in. The work group were informed that the section was protected. The driver of W532 travelling on the Up[1] main line sounded the horn when he saw workers on the tracks 40 to 60 metres ahead of the train. The work group, evacuated to a safe place beside the Up main line. The workers had cleared the tracks approximately three to four seconds before W532 passed their location.

There were no injuries to people or damage to property.

What the ATSB found

The Australian Transport Safety Bureau found that safety critical communication lacked confirmation between the signaller at Mount Victoria (SMV) and the protection officer[2] (PO) for the work group.

The PO became distracted during the establishment of worksite protection while he was attempting to conduct multiple tasks. The PO was communicating with the SMV, his work group and also the hand signaller at Mount Victoria (HSMV). This resulted in him overlooking information regarding the presence of a passenger train within the limits of the worksite and directing his work group to commence work on track.

What’s been done as a result

As a result of this incident and other recent safe working incidents, Sydney Trains launched the safety initiative “Safety Together: It Starts With Me”. The initiative focussed on ensuring all employees had an adequate understanding of the protection in place prior to the commencement of their work.

Safety message

Rail operators should remind rail safety workers of the importance of effective communications. All safety critical messages should be repeated by the receiver to confirm the detail of the message. If the sender is unsure that the receiver has understood the message, then the sender should challenge the receiver to repeat the message. This confirmation is especially important with regard to providing detail of train movements in the vicinity of the worksite.


  1. Trains travelling on the Up line are usually travelling towards Sydney Central Station; trains travelling on the Down line are travelling away.
  2. The Qualified Worker responsible for protection.
Download final report
[Download  PDF: 630KB]

The occurrence

Safety analysis


Safety action


General details
Date: 02 September 2018   Investigation status: Completed  
Time: 0811 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Blackheath   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 25 February 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Sydney Trains  
Train operator NSW Trains  
Train registration W532  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Mount Victoria, New South Wales  
Destination Sydney Terminal, New South Wales  
Last update 20 July 2020