Rail safety investigations & reports

Near hit with rail worker by passenger train 283D Dora Creek, New South Wales on 9 May 2020

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


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What happened

On Saturday 9 May 2020, NSW TrainLink passenger service 283D, an 8-car H OSCar set, travelling from Newcastle to Sydney, encountered a rail worker on the Up Main track at approximately 130.500 km. The worker saw and heard the approaching train and removed themselves from the track and out of the danger zone.

The train stopped past the location where the worker was situated, and the driver spoke with the worker to understand what had happened. The driver learned that the worker was an outer handsignaller (OHS) for a Track Work Authority (TWA) worksite at Dora Creek bridge at 127.100 km.

The OHS had been instructed by the protection officer (PO) for the worksite to remove the railway track signals[1] (RTS) being used for protection for the TWA. This instruction was made in the knowledge there was a train approaching the OHS location, but no warning or other information was relayed to the worker in relation to the proximity of the train.

What the ATSB found

An unapproved practice occurred during the application of the approved method of protection of TWA. This practice involved the person managing the safeworking, the PO, instructing workers to remove the RTS used to protect the worksite while trains were closely approaching. This was for the purpose of improving train operations. This practice put the track worker involved at risk as there was no defined process or method for protecting this worker. This practice was not part of the recognised methodology of using a TWA as published by the Rail Infrastructure Manager, Sydney Trains.

What has been done as a result

Sydney Trains acknowledged an unapproved practice occurred during the TWA whereby workers were directed to remove RTS while the train was closely approaching its location. Sydney Trains have included this issue in their change request process for Network Rules. The amendment will reinforce the existing requirement in step 12 of NPR 702 as it relates to a TWA using an inner and outer handsignaller protection, in that both the inner and outer protection must be replaced immediately after the passage of each rail traffic movement.

Safety message

Network Rules and Procedures for safeworking on railways have been developed to give direction and instruction to workers in how to safely manage work on track. When practices develop that deviate from the established procedures, care needs to be exercised to ensure these practices do not introduce unintended risk. Rail safeworking practices should only be implemented as approved by the Rail Infrastructure Manager.



  1. Railway track signal: A device attached to a rail that explodes on impact, used to attract attention of drivers and track vehicle operators.
Download Final report
[Download  PDF: 2.4MB]

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions

Table of abbreviations

Safety Issue

Go to RO-2020-006-SI-01 -

Unapproved practice during TWA

There was an unapproved practice occurring during Track Work Authority of asking the Outer Handsignaller to remove Railway Track Signals from the track as a train was closely approaching in order to let it run free, which placed the Outer Handsignaller at risk of being struck by the train.

Safety issue details
Issue number: RO-2020-006-SI-01
Status: Open – Safety action pending
General details
Date: 09 May 2020   Investigation status: Completed  
Time: 1526 AEST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Dora Creek   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 20 May 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Sydney Trains  
Train operator NSW TrainLink  
Train registration 283D  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Newcastle, New South Wales  
Destination Sydney, New South Wales  
Last update 27 May 2021