Rail safety investigations & reports

Pacific National grain train 5KC3 passing a series of signals passed at danger near Wagga Wagga, New South Wales, on 1 March 2019

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


Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. This statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance.

Overview of the investigation

At 0504 Eastern Daylight-Saving Time on Friday 1 March 2019, Pacific National (PN) grain train 5KC3 passed signal 04 26 at stop at Wagga Wagga while on a journey from Ararat, Victoria to Cootamundra, New South Wales. The train continued its journey north, passed another two signals at stop and through a set of points in Wagga Wagga yard. The train was stopped after the Australian Rail Track Corporation (ARTC) Network Controller contacted the train crew by radio and informed them of the signals passed at danger events. The train crew consisted of two persons, driver 1 and driver 2.

Train 4BM9 had departed Bomen and was heading towards Wagga Wagga to cross train 5KC3 when train 5KC3 passed the signals at stop. Train 5KC3 passed the up direction starting signal for the Wagga Wagga to Bomen section and was heading into a potential collision with train 4BM9. The two trains were around 2.5 km apart by the time they were both brought to a stand.

The investigation found that the crew of train 5KC3 did not react to the signal indications within Wagga Wagga yard limits that were set, at first to restrictive indications, and then stop indications. These signals were set to cross train 4BM9 at Wagga Wagga. The reason for the crew of train 5KC3 not responding to the signal indications could not be conclusively determined.

The data logger of the leading locomotive of train 5KC3 indicated the driver was successfully responding to the demands of the vigilance control system.

There was no evidence either of the crew of 5KC3 were affected by any medical or other health episode. Neither of the crew members can recall their journey beyond the southern entrance to Wagga Wagga yard limits until the notification of the signal passed at danger (SPAD) events by the ARTC Network Controller. Both crew members commenced their shifts at about 2000 the previous evening and their recent shifts were not regarded as being outside the normal rostering parameters for the operator.

The reasons for the train crew not responding to the signals may have been determined if the driver’s cab was fitted with an inward-facing camera recording the actions of the train crew. The video may have shown what the train crew were doing leading up to the SPAD. The presence of a camera would not have prevented the SPAD but may have assisted in the post-incident analysis. An audio recording, synchronised with the camera, may have also provided additional information about the train crew’s actions, and possible alarms or sounds inside the cab. Having audio and video recording allows investigators to eliminate potential contributory factors early in the investigation.

The Office of National Rail Safety Regulator (ONRSR) has consulted with key stakeholders regarding a requirement for Australian rail operators to install in-cab audio and video recorders in driver’s compartments. The finalisation of this process would be beneficial to the understanding of in-cab interactions of train crew and may lead to the development of new or improved risk mitigation measures.

Another ATSB investigation, involving a collision between freight trains 7MP5 and 2K66, at Jumperkine, Western Australia, on 24 December 2019, is currently examining vigilance control activation issues. In that investigation, the driver of 7MP5, operated by Pacific National, continued towards Jumperkine, without appearing to undertake any driver control changes that would have reset the vigilance time count. This investigation is expected to be completed in Quarter 4 2021.

The issue of drivers’ being unresponsive to signals while continuing to acknowledge vigilance alerts has been identified in previous rail investigations including Beresfield[1] and Hurlstone Park.[2] It may be beneficial if the effectiveness of vigilance control systems is explored as part of a separate safety study, and this is currently being considered by the ATSB.

Reasons for the discontinuation

The contributing factors to this SPAD highlight the need for a positive train control system to provide additional control in the prevention of SPAD events and their subsequent consequences.

In response to the investigation, ARTC has advised their Advanced Train Management System (ATMS) is a project underway that will provide additional protection from the risk of SPAD. The ATMS can detect and intervene when a train is not being managed in accordance with speed and proceed authority instructions.

According to the ARTC, the ATMS provides the following features:

  • increased rail capacity, by allowing operations with smaller inter-train distances
  • increased safety, through limit of authority and speed limit enforcement and protection for trackside workers
  • improved reliability, through better on-time performance
  • improved efficiency and flexibility in network use
  • reduced operation and maintenance cost for trackside infrastructure
  • a modern platform capable of extension to meet future demand.

Based on this information, it was considered unlikely that further investigation would identify any systemic safety issues or additional opportunity for the enhancement of transport safety beyond the introduction of a positive train control system. Consequently, the investigation is discontinued.



  1. New South Wales Department of Transport. Independent Inquiry Report, Coal Train Collision, Beresfield, NSW, 23 October 1997.
  2. ATSB Rail Investigation (RO-2013-003) Multiple SPAD by freight train 9837, at Hurlstone Park, New South Wales, on 30 January 2013.
General details
Date: 01 March 2019   Investigation status: Discontinued  
Time: 0505 AEDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Wagga Wagga   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 20 April 2021   Occurrence category: Serious Incident  
Report status: Discontinued   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Australian Rail Track Corproation (ARTC)  
Train operator Pacific National  
Train registration 5KC3  
Type of operation Grain train  
Sector Freight  
Damage to train Nil  
Destination Carrington, NSW  

Train 2 details

Train 2 details
Train registration 5BM9  
Type of operation Goods train  
Sector Freight  
Damage to train Nil  
Departure point Brisbane, Queensland  
Destination Melbourne, Vistoria  
Last update 20 April 2021