Rail safety investigations & reports

Safeworking Irregularity, near Waterfall, NSW on 21 August 2019

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

Final report

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What happened

At approximately 0030 on 21 August 2019, freight train 4WM2 operated by Pacific National stopped at signal W26U near Waterfall, New South Wales. The train crew consisting of driver A and B were directed by the Waterfall Signaller at 0200 to remarshal the train. The train could not continue and was required to return to Coalcliff to clear the main line. The train consisted of three locomotives and a rake of 50 wagons.

Remarshalling the train required one of the drivers to enter the danger zone to apply hand brakes on the wagons. Driver A requested safeworking protection from the Waterfall Signaller before entering the danger zone. Driver A walked the length of the train applying hand brakes before returning to the locomotives.

The locomotives were detached and operated to Waterfall, before travelling to Helensburgh and returning to the stabled wagons near Waterfall.

On arrival at the stabled wagons, driver B requested safeworking protection from the Waterfall Signaller. Driver B entered the danger zone to release the hand brakes from the stabled wagons. At about 0417, driver A signalled (hand signals and red marker lights) to the driver of an approaching passenger train (404A) to stop. The train was travelling on the adjacent track towards driver B in the danger zone and the driver of 404A made an emergency brake application to stop the train. The train stopped before arriving at the location driver B and there were no physical injuries.

What the ATSB found

The safeworking network rule and procedure for protecting activities associated with in-service rail traffic were not used effectively to ensure workers were protected from rail traffic. The requests for protection were informal and did not detail the required activities or protection. Both drivers of 4WM2 unknowingly entered the danger zone without appropriate protection and were at risk of being struck by rail traffic.

There were multiple parties involved in the communication and decision making relating to the movements of 4WM2. This led to confusion and misunderstanding of the required activities and likely affected the actions of the Waterfall Signaller and train crew. Additionally, not all communications were conducted in accordance with the network rules.

What has been done as a result

The train crew and Waterfall Signaller underwent re-training and assessment before returning to rail safety work.

Sydney Trains reviewed the risk management processes applied by network operations and the processes relating to incident management. Pacific National reviewed the processes for protecting in­­‑service rail traffic and reinforced the requirements with train crew. 

Safety message

Rail infrastructure managers and rail transport operators must ensure that safety critical communication is conducted in accordance with network rules. Additionally, network controllers should consider the potential dangers train crews are exposed to before requiring them to enter the danger zone.

Workers must ensure they have appropriate safeworking protection in place before entering the danger zone and are protected from rail traffic. Workers must also ensure that rest periods are utilised to manage non-work related fatigue.

Download final report
[Download  PDF: 1.07MB]

The occurrence


Safety analysis


Safety actions

Sources and submissions

General details
Date: 21 August 2019   Investigation status: Completed  
Time: 0410 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Between Helensburgh and Waterfall   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 02 February 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Sydney Trains  
Train operator Pacific National  
Train registration 4WM2  
Type of operation Freight service  
Sector Freight  
Damage to train Nil  
Departure point Port Kembla, NSW  
Destination Melbourne, Victoria  

Train 2 details

Train 2 details
Line operator Sydney Trains  
Train operator NSW Trains  
Train registration 404A  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Helensburgh, NSW  
Destination Martin Place, NSW  
Last update 02 February 2021