The reporter, on behalf of multiple rail safety workers, has raised various safety concerns in relation to [operator] failing to address an increase in critical safety breaches, insufficient training and reporting culture concerns.
Critical safety breaches
The reporter advised there has been a significant increase in the amount of safety breaches this year to date including but not limited to;
- at least [xx] reported signal passed at danger (SPAD) incidents which is a significant increase to that of the previous year
- shunting operations, in particular limit of shunt and signal breaches
- trains being taken into traffic without required lighting.
Failure to appropriately address critical safety incidents
The reporter believes [operator] is not managing safety breaches and does not provide appropriate consequence to those who repeatedly fail to meet basic job role requirements, subsequently leading to further safety critical breaches. The reporter provided the example of drug and alcohol testing of train drivers which no longer occurs immediately after a SPAD event. Previously, drivers that passed a signal at danger were immediately removed from service and taken for drug and alcohol testing. Now, drivers involved in SPAD events are requested to continue service with a potential delay for drug and alcohol testing.
Training and driver shortage
The reporter states, 'Basic standards of competency and aptitude have been replaced with anything goes, as the driver shortage and desperation to qualify enough drivers to meet needs has become the priority. The [Operator] training department are just brushing people through into qualifications they do not have the competencies or aptitude for. If someone fails an assessment too many times, they are placed with an assessor who is known to pass people easily'. The reporter further states, 'The types of SPADs that are occurring are desperately indicative of the "house of cards" training that is being provided, and the move towards hiring unsuitable applicants'.
Reporting culture
The reporter advised, the operator takes a retaliatory approach to those who dare question their behaviour surrounding integrity and safety. The reporter provided an example of the issuing of a threatening written warning to a driver who queried a safeworking breach as the result of an error by Train Control.
The reporter additionally advised of a derailment that was falsely recorded and downplayed/changed to blame the equipment rather than the driver.
The reporter finally states, '[Operator] appears to be manipulating records of events and responses to events, downplaying the reality that there are major safety concerns being protected. There is zero confidence in the [Operator] as a place to report to. Even though ONRSR are notified by the [Operator] of certain types of incidents, we (drivers) do not trust that what the [Operator] reports to ONRSR, and what actually happens out in the field are the same. The concern is that the [Operator] downplay reality to ONRSR'.
The [Operator] acknowledges receipt of the REPCON report submitted to the Australian Transport Safety Bureau (ATSB) regarding concerns raised by multiple rail safety workers. We take all reports relating to rail safety seriously and appreciate the opportunity to address the issues identified. [Operator] is committed to maintaining the highest standards of safety across our operations and fostering a culture of transparency, accountability, and continuous improvement.
Critical Safety Breaches
The [Operator] acknowledges the concerns raised regarding the reported increase in critical safety breaches year-to-date, including (but not limited to):
- signal passed at danger (SPAD) incidents
- shunting operations breaches, particularly at the limit of shunt and associated signal infringements; and
- trains entering traffic without the required lighting.
The [Operator] takes these matters extremely seriously. Our priority is the safety of passengers, the public, and rail safety workers, and we are committed to immediate and sustained actions to remediate issues identified.
We achieve this through the following measures:
- All critical safety incidents (for example SPADs, collisions, serious rule breaches) are reported through the Safety Management System (SMS).
- Incidents are escalated to senior operational and safety leadership personnel within defined time frames, and ONRSR is notified in accordance with Rail Safety National Law (RSNL) requirements.
- Initial triage is conducted to confirm severity, classify the event, and determine investigation level.
- Investigations follow [Operator]’s safety investigation procedure aligned with Office of the National Rail Safety Regulator (ONRSR) guidelines.
Root Cause Analysis (RCA) is undertaken using recognised methodologies (for example ICAM or 5-Whys) to identify systemic, human, and technical contributors.
Evidence collection includes interviews, radio recordings, playbacks, data logs, CCTV, and operational reports/records.
Failure to appropriately address critical safety incidents
When a safety breach or incident occurs, the welfare of the driver, passengers and safety of the network is a priority. As the circumstances of every incident are different, it necessitates that actions are tailored to address the specific situation. For example, if involved in a low risk SPAD event, the driver of the train will be contacted by Network Control, and the situation will be discussed. They will be asked if they are okay to continue or whether immediate relief from duty is required. At the same time as this is occurring, the on-call Operations Manager is also contacted and advised of the situation. Based on available information at the time and in consultation with Network Control, the on-call Operations Manager then determines next steps. If the driver is okay to take the train to the next siding or depot location, then this will occur prior to the driver being relieved at an agreed nearby location (where it is more operationally practicable) such as a siding, station or depot. The driver may also be relieved on the spot should they require this. It should also be noted that under certain circumstances, for example when a serious incident like a fatality occurs, drivers are immediately relieved and not given the option to continue on.
The on-call Operations Manager coordinates post-incident drug and alcohol testing with operational staff as required and ensures that this occurs within a short time frame post incident. The testing is completed by an external contract service agreement in accordance with Rail Safety National Law and [Operator] policy. In the event a driver cannot produce a sample, in accordance with the [Operator]’s Alcohol and other Drugs Policy, they are issued with a collection letter stipulating that they must attend an authorised collection location within 24 hours of the issued letter.
Once the matter has been investigated, and any outcomes are identified resulting from the investigation such as human error or conduct not in accordance with a person’s training, then re-education and re-training is provided and/or the matter may be dealt with under the disciplinary process of the applicable Industrial Agreement. Any matter dealt with under a disciplinary process will often result in a penalty under that agreement. Such penalty outcomes can only be determined by the Managing Director or their delegate (typically the delegated authority is the head of a division such as a General Manager or Executive Director). These disciplinary matters are confidential in nature and are not shared or discussed with colleagues of the staff members involved.
[Operator] employees have received significant disciplinary outcomes, including dismissal from employment, resulting from their breaches in critical safety incidents.
Training standards and driver shortage
The [Operator] maintains a rigorous training and assessment framework that is fully compliant with all statutory and regulatory requirements. This framework is governed by the following obligations:
- Rail Safety National Law ([State]) – Section 117 and Regulation 30 mandate that rail transport operators ensure rail safety workers are competent to perform their duties safely.
- Australian Qualifications Framework (AQF) – All qualifications and units of competency delivered by [Operator] are nationally endorsed and meet AQF standards for vocational education and training. [Operator] delivers the TLI42622 Certificate IV in Train Driving within the scope of our Registered Training Organisation (RTO) accreditation.
- Standards for Registered Training Organisations (RTOs) 2015 – Enforced by the [State training regulator], these standards require assessment validation, qualified trainers and assessors, and continuous improvement. [Operator] is subject to regular [State training regulator] audits to ensure compliance.
- Office of the National Rail Safety Regulator (ONRSR) Guidelines.
Assessment Integrity
All training and assessment tools undergo validation in accordance with [State training regulator] and Australian Skills Quality Authority (ASQA) requirements. Development is undertaken collaboratively with Learning and Organisational Development (L&OD) and multiple Subject Matter Experts (SMEs). Validation ensures compliance with the principles of assessment (fairness, flexibility, validity, reliability) and the rules of evidence (validity, sufficiency, authenticity, currency). All assessors are qualified and subject to monitoring to maintain consistency and integrity in assessment decisions.
Reassessment and Competency Assurance
Candidates are permitted two assessment attempts under [Operator] RTO standards, with a third attempt at the discretion of the Training Manager in accordance with established procedures. Individuals who fail to meet competency requirements are removed from the program. [Operator] does not compromise standards to meet operational needs and, in fact, applies stricter requirements than those mandated under national guidelines.
Driver Shortage Allegations
While the rail industry faces recruitment challenges, [Operator] has not lowered training standards or expedited qualification processes. Every trainee must demonstrate full competency prior to qualification. Recruitment and training decisions remain governed by our compliance framework and safety obligations.
Continuous Improvement
[Operator]’s training programs are subject to ongoing review and enhancement based on:
- Findings from incident investigations, including SPADs.
- ONRSR advice and industry best practice.
- Feedback from assessors and SMEs.
Reporting Culture
The [Operator] acknowledges the concerns raised regarding the integrity of incident reporting and the suggestion that [Operator] may be manipulating records or downplaying safety issues. The [Operator] categorically rejects these allegations and reaffirms its commitment to transparency, compliance, and the highest standards of rail safety.
Under Section 226 of RSNL, rail transport operators are legally required to maintain accurate records of notifiable occurrences and provide these to ONRSR upon request. This section mandates that all records must be truthful, complete, and retained for the prescribed period, below is a summary of section 226:
Accuracy Required
If you provide information when complying with the RSNL, it must be truthful and complete—you cannot omit anything that would change its meaning.
Not Tolerating Fakes
You’re not allowed to knowingly submit false or misleading information, whether in words or documents, when reporting under the law.
Responsibility to Correct
If you realise a report or document you submitted is false or misleading, the law requires you to:
- clearly identify what is wrong and correct it; or
- attach a signed statement explaining what is misleading and why.
Applicable Penalties
- individuals can be fined up to $20,000.00
- corporations can face up to $100,000.00 in fines.
Section 226 ensures that all incident reports and records submitted to ONRSR are complete, transparent, and trustworthy. This protects the integrity of safety systems, empowers investigations, and builds public confidence.
Similarly, Regulation 57 of the Rail Safety National Law regulations prescribes the reporting requirements for Category A and Category B notifiable occurrences, including the time limit and method of reporting to ONRSR.
The [Operator] fully complies with these obligations. All notifiable incidents are reported to ONRSR within the required time limit, and in accordance with the ONRSR Guideline – Reporting Requirements for Notifiable Occurrences. Internal processes ensure that incidents are correctly categorised, reviewed, and escalated where necessary.
Conclusion
The [Operator] remains committed to accurate reporting and regulatory compliance. Allegations of record manipulation are inconsistent with our documented procedures and legal obligations. We encourage any individual with evidence of non-compliance to report it through the appropriate channels, including ONRSR.
ONRSR confirms receipt of ATSB REPCON report RR-2025-00082 regarding an operator failing to address an increase in critical safety breaches, insufficient training, and reporting culture concerns. ONRSR has reviewed the reporter’s concerns and operator’s response.
Noting there are several elements to the contents of the REPCON, ONRSR provides the following response:
Critical safety breaches
ONRSR is aware of the noted safety breaches and as part of its regulatory activities has formally conducted inspections in relation to SPAD risk management and the effectiveness of controls (this included the passing of Limit of Shunt Boards without authority). The most recent activity being November 2025.
The operator was able to demonstrate that they are continually reviewing the effectiveness of the controls in place to reduce and eliminate SPADs particularly in the areas of:
- investigations
- training and competency
- consultation.
Failure to appropriately address critical safety incidents
ONRSR does not engage with RTO’s on human resources decisions an operator makes following notifiable occurrences. ONRSR accepts the operator’s risk-based approach for the relief of rail safety workers for conducting post-occurrence drug and alcohol testing.
Training and driver shortage
As noted above, ONRSR has conducted formal inspections on the operator in relation to SPAD risk management and associated controls. Training and competency formed part of an inspection and at the time no adverse findings were made. ONRSR will continue to conduct regulatory activities on the operator including a focus on training competency.
Reporting Culture
ONRSR actively monitors the operator’s notifiable occurrences and has open dialogue with the operator on this matter. ONRSR frequently requests investigation reports conducted by the operator to provide ONRSR with assurances that notifiable occurrences are investigated thoroughly with factual evidence reviewed and corrective actions addressing both individual, systemic, and organisational contributing factors.
ONRSR may conduct investigations on the operator into any potential breaches of the Rail Safety National Law and regulations based on notifiable occurrences and other forms of intelligence.
ONRSR is not aware of the operator not reporting or under reporting notifiable occurrences.
ONRSR published guidance material
ONRSR has a range of guidance material published on the ONRSR website including safety management systems, notifiable occurrence reporting requirements, drug and alcohol testing, and investigation reports by rail transport operators that may provide additional relevant information.