Rail safety investigations & reports

Near hit with workers on track using Absolute Signal Blocking, Westmead, New South Wales, on 15 October 2019

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


Download Final report
[Download  PDF: 1.55MB]

What happened

On 15 October 2019, a Protection Officer (PO) arranged with the Westmead panel signaller at Granville signal box to implement protection for work on track by use of Absolute Signal Blocking (ASB).

ASB was authorised and signals GE455 and GE463 were set to stop and blocked to prevent access to the worksite. Train 133U left Parramatta station and the signaller set the route for the train and it passed signal GE463 on the Down West Main line. The train was on a route to travel through 727 points to then travel along the Down West Suburban line.

After passing the signal, the driver encountered three workers on the track in front of the train, two were in the four foot of the Down Main line and another was in the danger zone adjacent to them. The driver sounded the train whistle to alert the workers and they vacated the track and danger zone. The driver also applied the emergency brakes and stopped just near where the workers had been.

What the ATSB found

The investigation found the relief signaller at Granville signal box had mistakenly believed the workers were further away from the location that was provided in the agreed arrangements for ASB. This mistaken belief led to the signal protection for the worksite being removed to allow 133U to run on the Down Main to access 727 points.

The relief signaller and the PO had earlier discussed the need to divert trains around the worksite, but neither correctly comprehended the implications of doing this, that is, the diversion would route a train into the worksite. The relief signaller was possibly experiencing the effects of cumulative fatigue due to rostering issues as well as experiencing a high workload. The rostered signaller at the Granville signal panel was absent from their workstation at the time and the relief signaller was operating both the Granville and Westmead signal panels.

The lack of advance notification to the relief signaller about the intended work, and its consequent impact on train running, meant the relief signaller had to devise an improvised train operations plan with no notice, adding to the pressure of operating two signal panels concurrently.

The Network Rules and Procedures for ASB had very little direction and guidance to workers about how to manage the risk of clearing a protecting signal for an alternative route in order to run a train.

What has been done as a result

After this incident, Sydney Trains temporarily prohibited the practice of signallers being permitted to clear any signals used for ASB protection in order to run trains via an alternative route. Changes to the ASB rule and procedure were implemented in December 2020 to prohibit the clearing of the signal immediately protecting a worksite in order to run a train via an alternative route.

Safety message

Railway safeworking rules are in place to achieve safe rail operations and should be developed so that the desired outcomes are supported by suitable procedures.

Signallers are safety critical workers that perform work vital to the safe performance of the rail network. These workers require supervision and should be subject to suitable management arrangements to ensure compliance to relevant work instructions and requirements.

Download Final report
[Download  PDF: 1.55MB]

The occurrence


Safety analysis


Safety issues and actions


Sources and submissions

Australian Transport Safety Bureau


The ATSB is investigating a near miss between track workers and a moving passenger train on the down main line between Parramatta and Westmead, New South Wales, on 15 October 2019.

At approximately 2302, the Waratah train on run 133U departed Parramatta Station. The blocking facilities which had been placed on the absolute signals had been removed to route the train from the down main to the down suburban line via 727 points. The train effectively entered the ASB (Absolute Signal Block) worksite limits. The driver of run 133U was required to make an emergency brake application and stopped short of the civil work group. The civil work group consisted of four rail safety workers. The civil work group were on track to conduct welded track stability analysis measurements. A protection officer was facilitating access to the worksite with the Area Controller operating the Westmead Panel within Granville Signal Box. 

As part of the investigation, the ATSB will interview the civil work team, the signal controllers, the protection officer, the train crew and gather additional information such as workscope planning records, signal logs, and audio communication.

This investigation is being led by the New South Wales Office of Transport Safety Investigations (OTSI). OTSI conducts rail investigations in NSW on behalf of the ATSB under the Transport Safety Investigation Act 2003.

A report will be released at the conclusion of the investigation. However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate action can be taken.

Safety Issues

Go to RO-2019-018-SI-01 - Go to RO-2019-018-SI-02 - Go to RO-2019-018-SI-03 -

The ASB rule and procedure for using an alternative route

The ASB rule NWT 308 and procedure NPR 703 did not provide sufficient description for the task of using protecting signals for an alternative route. (Safety issue)

Safety issue details
Issue number: RO-2019-018-SI-01
Status: Closed – Adequately addressed

Signaller supervision

Sydney Trains did not provide supervision at Granville signal box to ensure there was adequate coverage on both signalling panels. (Safety issue)

Safety issue details
Issue number: RO-2019-018-SI-02
Status: Closed – Adequately addressed

Inconsistencies with application of fatigue management system

There were inconsistences with Sydney Trains’ application of their fatigue management system, in particular the the use of a bio-mathematical model to predict individual fatigue risk. (Safety issue)

Safety issue details
Issue number: RO-2019-018-SI-03
Status: Closed – Adequately addressed
General details
Date: 15 October 2019   Investigation status: Completed  
Time: 2304 AEDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Westmead,   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 20 December 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Sydney Trains  
Train operator Sydney Trains  
Train registration 133U  
Type of operation Suburban Passenger Train  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Central Station  
Destination Penrith Station  
Last update 20 December 2021