OTSI Rail Safety Investigations
The Office of Transport Safety Investigations (OTSI) is an independent statutory body established by the government of New South Wales, Australia. Its head, the Chief Investigator, reports directly to the Minister for Transport.
OTSI was established as an independent body to investigate safety occurrences involving bus, ferry and rail transportation. The purpose of these investigations is to identify why an occurrence took place and make recommendations to prevent recurrence. To support this style of investigation, a 'just culture' approach is used.
OTSI's Chief Investigator has the discretion to choose which transport safety occurrences OTSI will investigate. The Minister may also direct that an investigation takes place. In determining what to investigate, the Chief Investigator considers the following aspects:
- The potential safety value that may be gained by conducting an investigation.
- The number of fatalities or injuries and level of property damage.
- The public profile of the occurrence.
- The availability of OTSI resources to perform the investigation.
- The risk associated with not investigating the occurrence.
- The requirement to investigate at the direction of the Minister.
- All investigations conducted by OTSI are solely for the purpose of identifying why an accident or incident happened and to make recommendations to prevent a similar occurrence happening in the future.
As a result of this objective, investigations are conducted within a 'just culture' that does not seek to apportion blame. However, if it is apparent that the safety occurrence was the direct result of a malicious act, then the matter will be passed to the appropriate regulator or enforcement agency.
The OTSI web site is http://www.otsi.nsw.gov.au/. Please refer to this site for full details of OTSI and all OTSI reports.
Documents
Interim Factual Statement: Runaway Rolling Stock Enfield Yard - 3 May 2011
Office of Transport Safety Investigation
At approximately 12.45 pm on 03 May 2011, a rake of 28 wagons loaded with aggregate (total mass in excess of 2500t) ran away from North Road No.1 in Enfield Yard and through the yard before colliding with a rake of 15 empty fuel tanker wagons and three flat bed wagons stabled in South Road No.1. The force of the collision caused the tanker bogie closest to the point of collision to derail. The bogie continued, in a derailed state, until encountering some points which caused the other bogie and both bogies of the tanker immediately in advance to derail all wheels with the tankers slewing across the track and carrying away an overhead wiring stanchion. The combined runaway came to rest over 400m from the point of collision with the tankers foul of the Up and Down Main freight lines.
The rake of aggregate wagons was undergoing maintenance at the time of the runaway, with some brake shoes being replaced. The handbrakes applied at the time of the incident did not hold the rake on the prevailing grade. The qualified Terminal Operator who was working on the rake attempted to apply more brakes but was not successful in arresting its movement. The rake continued its unauthorised and uncontrolled movement through Enfield Yard, the points lying such that it was routed into South Road No.1. The Signaller at Enfield became aware of the unauthorised movement and his mimic board indicated that Through Road No.1 and a section of the adjacent Up Main line were occupied. The Signaller placed blocks on signalling equipment to prevent the approach of rail traffic to the affected area.
The runaway and subsequent collision and derailment caused significant damage to rollingstock, overhead wiring equipment, and to track and signalling infrastructure. There were no injuries reported as a result of the incident.
Interim Factual Statement: Collision Between Hi-Rail And Rail Motor Zig Zag Railway - 1 April 2011
Office of Transport Safety Investigation
At 1:30pm on 1 April 2011, a Zig Zag Railway maintenance vehicle (the Hi-Rail), carrying two employees, collided with a two-car Rail Motor on the No 1 Viaduct, Top Road, between Clarence and Top Points stations. The Hi-Rail was travelling backwards in the section from Clarence towards Top Points and the Rail Motor was travelling in the opposite direction up from Top Points. The Rail Motor was operated by a Driver with no other persons onboard.
The force of the collision wedged the rear of the Hi-Rail into the front of the Rail Motor and both vehicles locked together. The two occupants of the Hi-Rail were injured in the collision and were assisted out of the Hi-Rail and onto the Rail Motor by the Driver of the Rail Motor, who was uninjured. As the Rail Motor reversed back towards Top Points the Hi-Rail dislodged itself from the Rail Motor and derailed. The Hi-Rail was left behind and the Rail Motor proceeded to Top Points and then to Bottom Points Station from where the two injured employees were then taken to hospital.
The Rail Motor sustained damage to its front panels and cow catcher and the Hi-rail sustained substantial structural damage to the rear tray which caused both cabin doors to jam closed. A portion of track in the vicinity of the collision suffered a minor misalignment.
Interim Factual Statement Uncontrolled Movement of El Zorro Grain Service 3996 Unanderra -7 Feb 2011
Office of Transport Safety Investigation
At 6:35am on 7 February 2011, El Zorro grain service 3996 en route from West Wyalong to Port Kembla Inner Harbour passed signal WG1014 which was at stop without authority. The train came to a stand 527m beyond the signal on the Up Main Line in the Unanderra – Unanderra North Section. 3996 consisted of 40 wagons loaded with wheat hauled by an EL Class engine and a VL Class engine.
The Driver reported that he had reduced speed to 7km/h at approximately 5km from Unanderra. He controlled the train speed using both dynamic and air brakes. However, at approximately one kilometre from Unanderra, he found that he was unable to properly control the train speed as it descended the 1 in 30 gradient. He then attempted to stop the train using full air brake but it did not stop until after it had passed signal WG1014.
The incident did not result in any injuries or damage.
Interim Factual Statement Near Miss With Track Cleaning Contractors Bankstown - 29 October 2010
Office of Transport Safety Investigation
At 12:45am on 29 October 2010, a team of five track workers employed by Swetha International Pty Ltd, under contract to RailCorp, commenced rubbish removal work on the tracks at Bankstown Railway Station.
At approximately 12:53am an empty CityRail train travelling from Sefton Park to Sydenham approached on the track on which the team was working. Seeing the workers ahead on the track, the driver sounded the horn and engaged emergency braking, stopping the train an estimated 100 metres short of the workers.
Given that OTSI is already investigating two separate incidents involving rail safety workers on tracks, the Chief Investigator directed that a rail safety investigation pursuant to Section 45A of the Transport Administration Act 1988 and Section 67 of the Rail Safety Act 2008 be commenced.
Level Crossing Collision Report Private Level Crossing at 594.680KMS Wee Waa - 1 September 2010
Office of Transport Safety Investigation
At approximately 7:40am on 1 September 2010, two Pacific National (PN) locomotives, operating as train D551, struck a road motor vehicle (RMV) on a private level crossing located in the Narrabri West to Wee Waa section approximately four kilometres East of the township of Wee Waa. As a result, the driver of the RMV, a 32 year old resident from Wee Waa, suffered fatal injuries. No crew members of D551 were injured but they were treated for shock.
Level Crossing Collision Report Private: Level Crossing at 594.680KMS Wee Waa - 1 September 2010
Office of Transport Safety Investigation
At approximately 7:40am on 1 September 2010, two Pacific National (PN) locomotives, operating as train D551, struck a road motor vehicle (RMV) on a private level crossing located in the Narrabri West to Wee Waa section approximately four kilometres East of the township of Wee Waa. As a result, the driver of the RMV, a 32 year old resident from Wee Waa, suffered fatal injuries. No crew members of D551 were injured but they were treated for shock.
Rail Safety Investigation Interim Factual Statement Track Worker Fatality Kogarah - 13 April 2010
Office of Transport Safety Investigation
A short time after 1:00am on 13 April 2010, five track workers employed by Swetha International Pty Ltd, under contract to RailCorp, commenced rubbish removal work on the tracks at Kogarah Railway Station.
At approximately 1:08am, a CityRail inter-urban service proceeded into Kogarah Station in transit to Central Station. The workers were on the track on which the train was travelling and although they moved to get out of the path of the train, one of them was struck by the train and fatally injured.
OTSI investigators attended the accident site and commenced a rail safety investigation pursuant to Section 45A of the Transport Administration Act 1988 and Section 67 of the Rail Safety Act 2008.
Unsecured Container Gate Strikes Station Infrastructure Woy Woy - 11 April 2010
Office of Transport Safety Investigation
At approximately 11:45am on 11 April 2010, Pacific National freight service 7MB4 was travelling through Woy Woy Station when an unsecured gate on container BSCF 215 became detached after hitting the fencing at the Sydney end of Platform 1 and then striking another fence on the end of Platform 2. The gate skidded across the platform for approximately 20 metres before smashing a seating bay glass windbreak panel and coming to rest on the platform. The dislodged gate narrowly missed striking members of the public waiting on the platform but, despite a number of people being showered with broken glass, only one person suffered minor injuries.
Rail Safety Investigation Report: Near Strike With Signal Maintenance Staff Strathfield - 1 Apr 2010
Office of Transport Safety Investigation
Shortly after 5:00am on 1 April 2010, the Driver of N804 CityRail Gosford to Sydney Terminal interurban service reported to the Area Controller at Strathfield Signal Control Centre that his train had nearly struck four members of a signal maintenance team working at 538A points on approach to Platform 1 at Strathfield Station. The Team had been called by the Area Controller to attend 538A points which had failed.
Interim Factual Statement: Derailment of Empty Grain Train 2531 Wittingham - 13 March 2010
Office of Transport Safety Investigation
At approximately 9:45am on 13 March 2010, empty Pacific National grain service 2531, enroute from Sulphide Junction (Newcastle) to Werris Creek, derailed as it traversed No. 203 points at Whittingham, on the Main North line approximately four kilometres south of Singleton in the Hunter Valley Region of NSW. No. 203 points provide access to the branch line leading to the Saxonvale coal mine.
Monorail Collision Darling Park - 27 February 2010
Office of Transport Safety Investigation
about 4:00pm1 on Saturday 27 February 2010, a Veolia Transport Sydney Metro monorail (Monorail 1) carrying 15 passengers collided with the rear of a stationary monorail (Monorail 4) at Darling Park Station, Darling Harbour, Sydney. Monorail 4 had 45 passengers on board and was experiencing door problems which caused it to stand at the Darling Park Station for longer than normal. It had just completed loading passengers and the doors on five carriages were still in the open position when it was hit from behind by Monorail 1 which at the time of impact was estimated to be travelling at 6m/s (22km/h). Four passengers from Monorail 1 sustained minor injuries and three were transported to hospital for treatment. No one on Monorail 4 was injured.
Rail Safety Investigation Report: Safeworking Breach Glenlee - 28 October 2009
Office of Transport Safety Investigation
At approximately 1:44pm on 28 October 2009 at Glenlee, Pacific National (PN) freight train 3BM4 almost struck the Co-driver of another PN freight train, 2XW4, who was returning to his locomotive after conducting an axle bearing inspection. The Codriver believed there would be no trains running on the adjacent ‘Down Main’ line after communicatin
Rail Safety Investigation Report: Runaway Grain Wagon Temora - 28 Jul 2009
Office of Transport Safety Investigation
At approximately 3:05am on 28 July 2009, empty grain wagon CQGY 540S, owned by Chicago Freight Car Leasing Australia (CFCLA) and leased by El Zorro Transport (EZT), ran away from the Temora Wheat Sub-Terminal1 during a shunting operation to detach it from a train. The wagon was being detached for stowage and subsequent transfer to Junee for scheduled maintenance requirements and because of defects identified during a previous safety inspection.
Signal Passed at Danger by Track Machine Consist 8M71 Goobang Junction - 10 May 2009
Office of Transport Safety Investigation
On the morning of Sunday 10 May 2009, Track Australia was transferring two track machines from Dubbo to Cootamundra via Parkes on behalf of the Australian Rail Track Corporation (ARTC). The machines were operating in convoy with a ballast regulator leading and a tamping machine following. Both track machines were crewed by personnel from Track Australia and the convoy was running as train number 8M71.
Incident Investigation
Office of Transport Safety Investigation
On the morning of Sunday 10 May 2009, Track Australia was transferring two track machines from Dubbo to Cootamundra via Parkes on behalf of the Australian Rail Track Corporation (ARTC). The machines were operating in convoy with a ballast regulator leading and a tamping machine following. Both track machines were crewed by personnel from Track Australia and the convoy was running as train number 8M71.
Derailment of El Zorro Grain Service 8996 Near the Township of Peak Hill - 8 February 2009
Office of Transport Safety Investigation
At approximately 5:23pm 1 on 8 February 2009, El Zorro grain service 8996 derailed nine grain wagons approximately 7km North of Peak Hill in the Western region of NSW. The train consisted of four locomotives and 38 loaded grain wagons. The train was en route from Nyngan to Port Kembla at the time of the derailment. There were no injuries to the crew but there was extensive damage to 370m of track infrastructure and the nine wagons.
Derailment of Cityrail Passenger Service k496 Unandera - 24 January 2009
Office of Transport Safety Investigation
At approximately 2:35am on 24 January 2009, CityRail four-car Tangara passenger service K496 departed from Unanderra Station towards Signal WG1010 which was at stop. A loud noise from a passenger disturbance in the vestibule behind the Driver momentarily distracted him and, as a result, he allowed the train to pass Signal WG1010 at stop without authority (SPAD).
Derailment of Cityrail Passenger Service 37- K Homebush - 7 January 2009
Office of Transport Safety Investigation
At 4:43pm on 7 January 2009 at Homebush, a CityRail eight-car Tangara passenger service passed Signal ST265L at stop without authority (SPAD) and derailed on the catch-points. No injuries resulted directly from the derailment or subsequent detrainment of passengers. A minor injury was reported by a young man using crutches who sustained a suspected sprained wrist while climbing the stairs to exit the platform adjacent to the derailed train. The Office of Transport Safety Investigation’s (OTSI) Duty Officer was notified of the accident at 4:55pm by RailCorp. OTSI deployed two investigators to the scene.
Rail Incident Factual Statement: Level Crossing Fatality Duri, NSW - 24 September 2008
Office of Transport Safety Investigation
On 24 September 2008 at approximately 3.53pm, a 34 year old male motorcyclist collided with the side of RailCorp’s Xplorer passenger service at a level crossing in the township of Duri, near Tamworth, and sustained fatal injuries.
Derailment of Pacific National Service BO552 Breeza To Werris Creek Rail Section - 29 January 2008
Office of Transport Safety Investigation
At approximately 4:33pm on Tuesday, 29 January 2008, Pacific National Limited coal service BO552 derailed in the vicinity of Breeza approximately 16km North West of Werris Creek in NSW. BO552 consisted of two locomotives and 42 loaded coal wagons. The train was a regular coal service which had been loaded earlier that day at Boggabri and was en route to Port Waratah. The train crew reported that 19 wagons had derailed, commencing at the 10th wagon in the consist and leaving the remaining 14 on the track. The crew were uninjured and able to inform and update response teams of the situation.
Fatal Injuring of Two Rail Maintenance Workers Singleton, NSW - 16 July 2007
Office of Transport Safety Investigation
At approximately 5:48am on 16 July 2007, a signal electrician and his assistant (hereafter referred to as “the Electrician” and “the Electrician’s Assistant” respectively and collectively as “the two rail maintenance workers”) were struck and fatally injured by Pacific National’s coal service HV161 at No.56A points approximately 445m South of Singleton railway station.1 The two rail maintenance workers had been called-out to attend to the points which had malfunctioned earlier in the morning.
Derailment of Pacific National Empty Grain Service 9529 Connemarra - 8 February 2007
Office of Transport Safety Investigation
At approximately 3:00pm on Thursday 8 February 2007, 16 wagons of Pacific National’s empty grain service 9529 derailed in the rail section between Binnaway and Werris Creek at a locality known as Connemarra in North Western NSW. The train parted during the derailment when four derailed wagons concertinaed across the track. The other derailed wagons remained in a generally upright position.
Derailment of Pacific National Service 6BA6 Euabalong West - Matakana Rail Section - 14 January 2007
Office of Transport Safety Investigation
At 2:53pm on 14 January 2007, both Pacific National Limited (PN) and the Australian Rail Track Corporation (ARTC) notified the Office of Transport Safety Investigations (OTSI) Duty Officer that, at 2.32pm, PN’s ‘Super-Freighter’ service 6BA6 had derailed at high speed in the Euabalong West – Matakana section of the Defined Interstate Rail Network (DIRN). The Australian Transport Safety Bureau (ATSB) was notified and OTSI investigators deployed to the derailment site following advice from the ATSB that it would not be investigating the incident.
Derailment of Pacific National Service 5CM3 Griffith to Leeton Rail Section - 11 January 2007
Office of Transport Safety Investigation
At approximately 5:30pm on 11 January 2007, ten container wagons on Pacific National’s freight service 5CM3 derailed approximately 3km North West of Leeton in the Riverina region of NSW. The train consisted of three locomotives and 27 container wagons conveying 69 shipping containers, and was en route from Griffith to Melbourne.
Track Worker Injured by Hi-Rail Excavator Sandgate Rail Flyover Project - 7 November 2006
Office of Transport Safety Investigation
At approximately 1:10pm on Tuesday 7 November 2006, a 24 year-old male track worker was preparing to weld a newly-laid section of rail in an area where new track was being commissioned when he was struck by a reversing Hi-rail excavator1 operated on behalf of John Holland Rail. The track worker was severely injured, requiring hospitalisation and emergency surgery.
Derailment of Pacific National Ore Service 4835 Nevertire - Nyngan Rail Section - 1 October 2006
Office of Transport Safety Investigation
At approximately 5:46am on 1 October 2006, the trailing locomotive and 14 wagons within Pacific National Limited’s ore container service 4835 derailed four kilometres South-East of a locality known as Miowera, on a Class 3 freight line, between Nevertire and Nyngan in the Central West region of NSW. These rail vehicles, and 22 containers thereon, suffered varying degrees of damage. Fortunately, there were no injuries.
Derailment of Cityrail Service 312A Thirroul - 11 September 2006
Office of Transport Safety Investigation
At 5:32am on 11 September 2006, the leading car on CityRail’s passenger service 312A, operated by RailCorp, derailed at catch-points in the vicinity of No. 3 Platform at Thirroul after failing to stop at Signal WG 568D. On approach to the signal the train did not respond to normal braking techniques forcing the driver to apply his emergency brakes approximately 20 metres prior to the signal.
Signal Passed at Danger by Cityrail Service 67-R North Strathfield - 2 September 2006
Office of Transport Safety Investigation Report 04315
At approximately 1:08am (Eastern Standard Time) on 2 September 2006, an empty CityRail service 67-R passed Signal ST 164 at stop without authority on the ‘Down Relief’ line at North Strathfield and continued onto the single, bi directional ‘Goods’ line between North Strathfield and Homebush, as the points were set for this route. At the same time, Pacific National’s freight service 5YN2 was travelling on the same ‘Goods’ line between Flemington and Homebush, but in the opposite direction. 67-R and 5YN2 were proceeding towards each other on the same line.
The Area Controller at Strathfield Signal Box witnessed the evolving opposing movement on his indication board and attempted to contact the Drivers of 67-R and 5YN2 by radio to direct them to stop their trains immediately. The Driver of 5YN2 responded by stopping his train as directed. However, the Area Controller was unable to establish radio contact with the Driver of 67-R because the Driver had entered the wrong train designation, or run number, when he logged into the radio network. In the meantime, a number of other Area Controllers stood on the balcony of the Strathfield Signal Box and tried to attract the attention of the Driver of 67-R in an attempt to warn him of the impending danger. The Driver was unaware of these attempts to contact him but eventually realised that he was on the wrong line and bought his train to a stand adjacent to the Strathfield Signal Box and some 194 metres from the stationary 5YN2.
There was no injury or damage resulting from the incident.
Self-Harm Fatality on the Eastern Suburbs Railway Town Hall - Central Tunnel Section- 30 August 2006
Office of Transport Safety Investigation
At approximately 4:25pm on Wednesday 30 August 2006, a 43 year old woman was struck and killed by CityRail passenger service 10-F in an underground section of the Eastern Suburbs Railway (ESR) between Town Hall and Central Railway Stations, approximately 238 metres North of Platform 25 at Central. The woman’s entrance into the tunnel was unauthorised and evidence acquired after the incident indicates that she was intent on committing suicide.
Track Worker Fatality Baan Baa - 22 May 2006
Office of Transport Safety Investigation
At approximately 9:00am on 22 May 2006, a track worker employed by the Rail Infrastructure Corporation (RIC) and seconded to the Australian Rail Track Corporation (ARTC) was fatally injured while participating in ballasting operations approximately 3km South of Baan Baa. The ballast train (5M23) was crewed by two Southern & Silverton Railway Pty Ltd (Silverton Rail) drivers and consisted of three locomotives and 22 ballast wagons, with a plough van at the rear.