Rail Safety Summary Report

RAIL SAFETY SUMMARY REPORT

CONTRIBUTING FACTORS IN NSW RAIL INCIDENTS 2004 – 2013

Contributing Factors in NSW Rail Incidents 2004 – 2013 i

RAIL SAFETY SUMMARY REPORT

CONTRIBUTING FACTORS IN NSW RAIL INCIDENTS 2004 – 2013

Released under the provisions of Section 45C (2) of the Transport Administration Act 1988 Investigation Reference 04679

Published by: The Office of Transport Safety Investigations Postal address: PO Box A2616, Sydney South, NSW 1235 Office location: Level 17, 201 Elizabeth Street, Sydney NSW 2000 Telephone: 02 9322 9200 Accident and incident notification: 1800 677 766 Facsimile: 02 9322 9299 E-mail: [email protected] Internet: www.otsi.nsw.gov.au

This Report is Copyright©. In the interests of enhancing the value of the information contained in this Report, its contents may be copied, downloaded, displayed, printed, reproduced and distributed, but only in unaltered form (and retaining this notice). However, copyright in material contained in this Report which has been obtained by the Office of Transport Safety Investigations from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where use of their material is sought, a direct approach will need to be made to the owning agencies, individuals or organisations.

Subject to the provisions of the Copyright Act 1968, no other use may be made of the material in this Report unless permission of the Office of Transport Safety Investigations has been obtained.

THE OFFICE OF TRANSPORT SAFETY INVESTIGATIONS

The Office of Transport Safety Investigations (OTSI) is an independent NSW agency whose purpose is to improve transport safety through the investigation of accidents and incidents in the rail, bus and ferry industries. OTSI investigations are independent of regulatory, operator or other external entities.

Established on 1 January 2004 by the Transport Administration Act 1988, and confirmed by amending legislation as an independent statutory office on 1 July 2005, OTSI is responsible for determining the causes and contributing factors of accidents and to make recommendations for the implementation of remedial safety action to prevent recurrence. Importantly, however, OTSI does not confine itself to the consideration of just those matters that caused or contributed to a particular accident; it also seeks to identify any transport safety matters which, if left unaddressed, might contribute to other accidents.

This OTSI rail safety summary report was initiated in accordance with the provisions of the Transport Administration Act 1988.

OTSI Rail Safety Summary Report

TABLE OF CONTENTS

TABLE OF FIGURES iii Abstract 1 Introduction 2 Contributing Factors Framework 2 Occurrence categories 3 Analysis of contributing factors from OTSI rail reports 5 Individual/team actions 6 Technical failures 7 Local conditions/organisational factors 8 Local conditions 10 Organisation factors 15 Investigation report summaries and contributing factors 20 1. Baan Baa - Level Crossing Collision - 4 May 2004 21 2. Port Botany - Shunting Fatality - 1 July 2004 23 3. Bethungra - Derailment - 22 December 2004 25 4. Lapstone/Wauchope - Derailment – 1 & 7 March 2005 27 5. Old Burren - Derailment - 6 April 2005 29 6. Grawlin Plains - Level Crossing Collision - 31 May 2005 31 7. Bloomfield- Opposing movement - 20 August 2005 33 8. Steel sleepers – Systemic report -2005 36 9. Conoble- Derailment - 16 October 2005 38 10. Lidcombe - Derailment – 4 November 2005 40 11. Ariah Park – Shunting fatality – 15 April 2006 42 12. Baan Baa – Ballast wagon fatality – 22 May 2006 45 13. Town Hall Tunnel - Self harm fatality - 30 August 2006 47 14. North Strathfield – Opposing movement – 2 September 2006 49 15. Thirroul – SPAD and derailment – 11 September 2006 51 16. Nyngan – Derailment – 1 October 2006 53 17. Sandgate – Track work injury – 7 November 2006 55 18. Leeton – Derailment – 11 January 2007 57 19. Euabalong West – Derailment – 14 January 2007 60 20. Connemarra – Derailment – 8 February 2007 62 21. Singleton – Track worker fatalities – 16 July 2007 64 22. Breeza – Derailment – 8 January 2008 67 23. Homebush – SPAD and Derailment – 7 January 2009 69 24. Unanderra – SPAD and Derailment – 24 January 2009 71

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25. Peak Hill – Derailment – 8 February 2009 74 26. Goobang – SPAD and collision – 10 May 2009 77 27. Temora – Runaway wagon – 28 July 2009 79 28. Glenlee – Safeworking breach – 28 October 2009 81 29. Darling Park – Monorail collision – 27 February 2010 83 30. Whittingham – Derailment – 13 March 2010 85 31. Strathfield – Near strike of maintenance staff – 1 April 2010 87 32. Woy Woy – Unsecured container gate – 11 April 2010 90 33. Kogarah – Track worker fatality – 13 April 2010 92 34. Wee Waa – Level crossing collision – 1 September 2010 96 35. Bankstown – Near miss with track workers – 29 October 2010 98 36. Unanderra – Uncontrolled movement – 2 February 2011 100 37. Zig Zag – Collision between a train and a Hi-rail – 1 April 2011 102 38. Enfield yard – Runaway rolling stock – 3 May 2011 105 39. Woy Woy – Level crossing collision – 2 Sep 2011 107 40. Clifton – Broken axle derailment – 23 Nov 2011 109 41. Unanderra – Safeworking incident – 12 Dec 2011 111 42. Gunnedah – SPAD and opposing movement – 7 March 2012 113 43. Nundah – Level crossing collision – 7 May 2012 115 44. Bengalla – Ballast train collision – 18 May 2012 117 45. Summit Tank – Safeworking incident – 17 July 2012 120 46. Boggabri – Coal train derailment – 28 Nov 2012 122 47. Gulgong – Wagon structural failure – 5 Dec 2012 124 48. Rennie – Derailment – 3 January 2013 126 49. Moree – Level crossing collision – 21 May 2013 128 50. East Maitland – Safeworking incident – 27 November 2013 130 51. Moss Vale – Safeworking incident – 21 December 2013 132 Appendix A: Contributing factors framework overview 134 Appendix B: Contributing factors framework analysis 135 Appendix C: OTSI rail investigation reports with keywords 138 Appendix D: Incident notification and classification 142

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TABLE OF FIGURES

Figure 1: Reason’s model of organisational accidents 3 Figure 2: OTSI investigations classified using OC-G1 4 Figure 3: Main contributing factors groups 5 Figure 4: Individual/team action findings grouped by person type 6 Figure 5: Technical failure findings grouped by component area 7 Figure 6: Local conditions and organisational factors 8 Figure 7: Knowledge, skills and experience type findings 10 Figure 8: Task demands type findings 11 Figure 9: Personal factors type findings 12 Figure 10: Physical environment type findings 13 Figure 11: Social environment type findings 14 Figure 12: Organisational management type findings 15 Figure 13: Equipment, plant and infrastructure type findings 16 Figure 14: Procedure type findings 17 Figure 15: People management type findings 18 Figure 16: Training and assessment type findings 19

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Abstract

The aim of this report is to record in summary form the results of the classification and analysis of the findings from Office of Transport Safety Investigations rail safety investigations.

All the findings from the 51 rail safety investigations undertaken in the 10 year period from 2004 to 2013 were examined. The contributing factors were then identified and coded in accordance with a Contributing Factors Framework based on Professor James Reason’s Model of Organisational Accidents. Of the total of 346 findings, 277 (80%) were classified in the contributing factors group of organisational factors/local conditions. Individual/ team actions contributed on 49 occasions and technical failures on 20 occasions. The findings are further classified within each main contributing factors group. The results are presented in graphical form together with examples from the investigations.

The report contains a brief overview of each investigation accompanied by general occurrence information. All related findings are tabulated along with their contributing factors framework details.

No specific recommendations are made in this report. However, rail industry stakeholders would benefit from using the contributing factors framework as a method to analyse findings from investigation reports. This would facilitate comparison of contributing factors as a means to better understand frequently occurring issues and possible industry-wide trends.

Contributing Factors in NSW Rail Incidents 2004 – 2013 1 OTSI Rail Safety Summary Report

Introduction

This report records the results from the analysis and classification of the findings from Office of Transport Safety Investigations (OTSI) rail safety investigations.

The classification system used is the Contributing Factors Framework (CFF), an overview of which is included in Appendix A. The Rail Safety Regulators Panel published the CFF to assist interested parties in classifying the key findings of rail safety investigations. The CFF was developed by a working group comprised of representatives from Australian safety regulators, the rail industry, and independent rail safety investigation agencies. Work on the framework began in 2005 and the first version was published in February 2009. OTSI has applied the framework to its rail investigation findings progressively since its introduction. The aim of the framework is to:  provide a structured and consistent framework to code the systemic contributors to incidents and accidents  facilitate the analysis of aggregate data to identify patterns and trends in safety issues  assist in making informed decisions on safety issues and enhance continual improvement practices.1

Contributing Factors Framework

The CFF is based on the Professor James Reason Model of Organisational Accidents2 which has been widely adopted across the rail industry and other safety critical industries. This adapted model is illustrated in Figure 1.

This model starts with the organisational factors such as strategic decisions and organisational processes. The processes are influenced by the corporate culture of the business. These processes transfer throughout the organisation and give rise to task and environmental conditions that are likely to lead to violations and errors by individuals/teams in the workplace, or to technical failures.

1 Rail Safety Regulators Panel (2011): Contributing Factors Framework Manual, Version 2, p.8. 2 Ibid., p.16.

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Contributing factors

Organisation Local Individual / Direct Conditions Teams failure pathway Management Workplace - Errors & systems, Task / violations decisions & Environment organisational Occurrence processes Error and violation Technical producing failures conditions

Latent failure pathway

Social, Political, Regulatory & Investigation pathway Economic environment…

Figure 1: Reason’s model of organisational accidents

The CFF coding process occurs after the formal investigation is concluded. The coding is then entered into a database for analysis and identification of systemic safety trends. A summary of the CFF applied to OTSI investigations is included in Appendix B.

The trends that have emerged from OTSI rail safety investigations are evident from the data presented in the first section of this report. The second section of this report provides a brief background summary for each investigation along with occurrence details. All related findings are then tabulated along with the results of the CFF analysis.

A list of OTSI rail safety investigations along with relevant CFF keywords is included in Appendix C. A full version of each investigation report is available on the OTSI website at otsi.nsw.gov.au

Occurrence categories

Every OTSI rail safety investigation report was classified according to the Occurrence Classification Guideline (OC-G1) (see Figure 2). Derailment was the most frequent investigation type. There were 20 derailment investigations, 11 collisions between rail vehicles, eight safeworking incidents, six level crossing collisions, and three signals passed at danger (SPADS). Two SPADs involved the driver completely missing the signal, while the other was a driver misjudgement.

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25 20 20

15 11 10 8 6 5 3 111 0

Figure 2: OTSI investigations classified using OC-G1

The complete list of OC-G1 occurrence categories and related OTSI investigations is contained in Appendix D. The number of OTSI’s investigations represents only a small sample of the large number of reported accidents and safety-related rail incidents. The number and categories of investigations should not be taken in any way to be proportionally representative of the total of reported incidents.

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Analysis of contributing factors from OTSI rail reports

During the period from 2004-2013 there were 345 findings recorded in the 51 OTSI investigations. There were 49 findings made about individual or team actions, 20 findings made about technical failures, and 276 findings made about organisational factors or local conditions (see Figure 3). ‘The evidence from a large number of accident inquiries indicates that bad events are more often the result of error-prone situations and error-prone activities than they are of error-prone people.’3

Individual / team actions, Technical 49 Failures, 20

Organisational Factors/Local conditions, 276

Figure 3: Main contributing factors groups

Most of the findings were classified in the organisational factors/local conditions category. Not all reports made findings about individual’s actions and only a small proportion of findings were about technical failures. These groupings of individual/team actions, technical failures, and organisational factors/local conditions are further analysed in the following sections of this report.

3 Reason, J. (1997). Managing the risks of organizational accidents, Ashgate, p.129.

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Individual/team actions

The individuals identified in the findings area of the individual/team action area were from the following groups: infrastructure maintainers, light passenger vehicle drivers, network controllers, rolling stock maintainers, terminal staff and train crew (see Figure 4). Station staff, heavy freight vehicle drivers or emergency services staff were not identified in any report.

Infrastructure maintainers, 14 Train crew, 17

Light passenger vehicle driver, Terminal 6 staff, 3 Network controller, 8 Rollingstock maintainer, 1

Figure 4: Individual/team action findings grouped by person type

Of the train crew identified seven were passenger train drivers, seven were freight train drivers, two were track machine operators and one was a guard.

The six light passenger vehicle drivers identified in the findings were all car drivers involved in incidents at level crossings.

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Technical failures

The technical failure components identified in the findings came from the following groups: infrastructure, rolling stock, and signalling and communications equipment (see Figure 5).

Signalling & communication equipment, 1

Rollingstock, 7

Infrastructure, 12

Figure 5: Technical failure findings grouped by component area

The condition of the track was identified as a contributing factor in all 12 instances of infrastructure failure. The origin of the failure was maintenance related in the majority of cases.

Bogies, braking systems, car bodies, and a train detection system were the component areas found to have contributed to rolling stock failures. A train detection system failure occurred in the monorail accident where the anti-collision emergency stop system on the monorail did not function as designed.

The signalling and communication failure resulted from a CCTV camera being sighted such that its field of vision was partially obscured by a platform structure.

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Local conditions/organisational factors

The analysis of organisational factors/local conditions found that organisational factor findings were made most often. The 276 findings were split between 102 local conditions and 174 organisational factors (see Figure 6).

Local Conditions, 102

Organisational factors, 174

Figure 6: Local conditions and organisational factors

‘Local conditions can be considered conditions present in the local workplace or environment in which the individual/team action or a technical failure occurs.’4 They are grouped under the following headings:  knowledge, skills and experience  personal factors  physical environment  social environment  task demands.

‘Organisation factors are those factors in the management system, decision-making at the senior level and policy settings that guide the activities of the organisation.’5 They can

4 Contributing Factors Framework Manual, Version 2, p.22. 5 Ibid., p.22.

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OTSI Rail Safety Summary Report sometimes be identified in organisations other than the one directly responsible for the occurrence.

Organisational factors are grouped as:  organisational management  equipment, plant and infrastructure  people management  procedures  training and assessment  external organisational influences.

These factors may be within the organisation’s internal or external environment.

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Local conditions

The most frequently identified local conditions findings were in the knowledge, skills and experience area. These included persons having trouble with normal operational tasks, lack of communication skills, inadequate task experience, poor abnormal/ emergency skills and deficient teamwork skills (see Figure 7).

20 19 18 16 14 12 11 10 8 7 6 5 4 2 2 0

Figure 7: Knowledge, skills and experience type findings

Examples of knowledge, skills and experience findings can be found in the following investigations:

 An abnormal/emergency skills finding was made in the 2005 Bloomfield opposing movement investigation. Neither train crew operated the emergency function on the radio system to report the incident because, having avoided a collision, they did not consider that they had been involved in an emergency.  In the 2010 Kogarah investigation recordings revealed that voice communications from train control were informal and not in accordance with network rules and procedures.  The 2012 Gulgong investigation found that a defective welded joint completed during a normal operational task was not detected during inspections. This contributed to a structural failure in a wagon.

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The next most common category was in the area of task demands (see Figure 8). The most significant factor in this area was distraction. Other factors identified were high workload, being under time pressure and familiarity with the task.

12 12

4 4 3

2 1

0 Distraction Time pressure High workload Familarity

Figure 8: Task demands type findings

Examples of task demand findings can be found in the following investigations:

 The 2006 Ariah Park investigation found that the shunter may have been distracted by the presence of spectators in close proximity as he attempted to couple the tender and the carriage.  At Singleton in 2007 a high level of task familiarity was found to have lessened the workers’ appreciation of the risks associated with their task. This accident resulted in two fatalities when the workers were struck by a train.  A high workload was found to have contributed to the 2009 Glenlee near miss when a driver returning from a train inspection was almost struck by an oncoming train on the adjacent track. The workload of network controllers was high prior to and at the time of the incident.  A near miss at Bankstown in 2010 occurred because a protection officer did not see workers enter the danger zone as he was distracted by using his mobile phone.  In 2010 at Strathfield a work team was under time pressure to perform a task. They had insufficient time to complete a full safety assessment and work plan in addition to all other necessary preparatory tasks. As a consequence, they were nearly struck by a passing train.

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There were 16 findings made in the area of personal factors. These included problems with fatigue/alertness, motivation/attitude, preoccupation, stress/anxiety and health (see Figure 9).

9 8 8 7 6 5 4 4 3 2 2 11 1 0

Figure 9: Personal factors type findings

Examples of personal factor findings can be found in the following investigations:

 The 2005 Lidcombe derailment investigation found that the driver was affected by fatigue as he had not slept well the night before his shift.  The investigation into the fatalities at Singleton in 2007 found that both workers had worked seven shifts over the preceding seven days. Consequently, both workers were probably suffering from a degree of fatigue.  The 2009 Peak Hill derailment investigation found that the co-driver was incapacitated through illness. Therefore, he was unable to perform his duties of maintaining a lookout and relaying trackside infrastructure information to the driver.  Similarly, the 2009 Unanderra SPAD and derailment investigation found that the guard was feeling stressed and unwell which affected his decision-making ability at a critical time.

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The physical environment was found to be a contributing factor on 15 occasions. The following factors were identified: lighting/visibility, noise, temperature/humidity, and weather related factors. There was one finding where an unstable surface contributed to the incident (see Figure 10).

9 8 8 7 6 5 4 3 222 2 1 1 0

Figure 10: Physical environment type findings

Examples of physical environment findings can be found in the following investigations:

 A noise-related finding was made in the 2006 Sandgate investigation into a track worker injury. The track worker’s ability to hear the approaching excavator would have been affected by the noise associated with the cutting and welding tasks he was performing, as well as the operation of trains on the adjacent lines.  An unstable surface contributed to a fatality at Baan Baa in 2006. Stepping onto a loosely-packed, rough, sloping ballast shoulder from a ballast machine increased the risk of an accident.  The 2012 Bengalla ballast train collision investigation found that the lights were not illuminated on a stationary track machine. Because it was a dark night, the pilot on the propelling train did not see the track machine until just before his train collided with it.

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The social environment was found to be a contributing factor on seven occasions. Norms and values and peer pressure were the two areas identified (see Figure 11).

6 5 5

3 2 2

0 Norms and values Peer pressure

Figure 11: Social environment type findings

Examples of social environment findings can be found in the following investigations:

 The investigation into a collision on the Zig Zag Railway in 2011 found there was an accepted practice of qualified workers authorising rail traffic movements without reference to the train controller. On the day of the incident a guard authorised a hi-rail movement resulting in it subsequently colliding with a train.  The 2012 Gunnedah SPAD and opposing movement investigation found that the co- driver was under training, was relatively inexperienced and an authority gradient existed between him and the driver. This contributed to him not taking more positive action when the driver did not comply with procedures in stopping the train before the signal.

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Organisation factors

The most frequently identified organisational factor findings were in the organisational management area (see Figure 12).

23 20 21

10 10

5 6 4 333 21 0

Figure 12: Organisational management type findings

Examples of organisational management findings can be found in the following investigations:

 A monitoring, review and validation finding was made in the 2008 Breeza derailment investigation. The rail was not adequately constrained against the forces on it due to ineffective anchoring. The task of replacing anchors following track work several months prior to the derailment had not been completed when the incident occurred.

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 The investigation into the uncontrolled movement of a train at Unanderra in 2011 found that the modifications made to the brake pipe of a particular class of wagons did not meet engineering requirements.

The next most common category was in the area of equipment, plant and infrastructure (see Figure13).

14 15

12 12 10

6 6 4 4 2 3 2 11 0

Figure 13: Equipment, plant and infrastructure type findings

Examples of equipment, plant and infrastructure findings can be found in the following investigations:

 The investigation into a railway crossing accident at Nundah in 2012 found the crossing did not fully meet the requirements of Australian Standards. There was no visible stop line accompanying the stop sign.  A safeworking incident occurred at Moss Vale in 2013. It was found that there were no designated locations where train crew could conduct axle bearing inspections after an axle alert was triggered by a trackside detector.

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In many incidents it was found that problems with procedures contributed to the incident occurring. There were 31 findings associated with procedures. These included problems with the accuracy or clarity of procedures, absent procedures, and one instance where the procedure was not available or accessible (see Figure14).

15 17

10 13

5 1 0 Accuracy / clarity Absent procedure Availability / accessibility

Figure 14: Procedure type findings

Examples of procedure findings can be found in the following investigations:

 Inspection standards for unit train maintenance not emphasising the examination of the axle barrel contributed to a derailment at Clifton in 2011.  An investigation into a derailment at Rennie in 2013 found there was not a standard or guideline to assist track managers in responding to unfavourable individual track geometry measurements.  In 2013 there was a safeworking incident at Unanderra where the investigation found that the train crew did not have access to procedures to check how protection should be requested and implemented.

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There were 10 findings associated with people management (see Figure15).

6 5 4 5 3 2 1 22 1 0 Job / task design Rostering /scheduling Supervision Fitness for duty monitoring

Figure 15: People management type findings

Examples of people management findings can be found in the following investigations:

 A train driver involved in an opposing movement at North Strathfield in 2006 had been rostered for nine consecutive days. The area controller had been rostered for eight consecutive days. These rostering arrangements were found to have contributed to the driver missing a signal.  At Whittingham in 2010 the supervisor did not adequately supervise a worker to ensure the route was correctly set after the points were set and clipped. As a result a freight train derailed on the points.  A specified welding process which made the weld technically difficult for the welder during manufacture was found to have contributed to the structural failure of a wagon at Gulgong in 2012.

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There was also a total of 11 findings associated with training and assessment (see Figure16).

6 5 4 5 3 2 1 222 0 Initial training Competency Currency tracking Ongoing training assessment

Figure 16: Training and assessment type findings

Examples of training and assessment findings can be found in the following investigations:

 At Kogarah in 2010 workers were caught on the track with a train approaching and no safe place readily accessible. During their induction and worksite protection training there was insufficient coverage of the emergency safety precautions to be taken in such circumstances.  An investigation into a safeworking incident at East Maitland in 2013 found that the on-job training provided to the protection officer was inadequate. Although the on-job workbook was signed off to confirm that he had demonstrated knowledge in a wide range of tasks and procedures, the reality was different.

The final category is external organisational influences. It had the least number of findings of any category. Within this category one finding was made concerning regulatory activities and one finding was made about industry standards.

These examples of external organisational influence findings can be found in the following investigations:

 The investigation into a derailment at Bethungra in2004 found that the NSW rail regulator did not have sufficient visibility of the condition of the track and related infrastructure.  The investigation into the uncontrolled movement of a train at Unanderra in 2011 found that there was no industry standard defining what constituted single and dual pipe wagons. Such a standard would be expected to cover various engineering aspects such as the purpose, application, flow rates and timing in reference to charge rates.

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Investigation report summaries and contributing factors

The following section contains a brief summary of each incident and the findings made for each investigation. The occurrence details are also provided with information on the number of injuries and fatalities, the event description and type of operation (passenger, freight or track maintenance) included in the details is the OC-G1 categorisation.

Occurrence details (Example shown below)

Event description: Passenger train collision with car at level crossing Type of operation: Passenger Fatalities 1 Injuries: 4 Occurrence Classification Level crossing occurrence Collision with road vehicle At crossing with passive warning devices: Stop signs

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1. Baan Baa - Level Crossing Collision - 4 May 2004

At 5.10pm a passenger service, carrying 33 passengers and three crew members, collided with a motor vehicle, with the driver as the sole occupant on the Baranbah Street Level Crossing at Baan Baa. Baan Baa is located between Boggabri and Narrabri in the Northwest Plains region of NSW. Following the collision, the leading carriage of the two carriage consist derailed and came to rest on its right side across the tracks approximately 420 metres beyond the crossing. The rear carriage remained upright.

As a result of the collision the driver of the car, who was a local resident, was fatally injured; four train passengers were hospitalised and a number of persons, both passengers and train crew, were treated on site for shock and minor injuries; the car was destroyed and there was considerable damage to the train and track. The rail line was closed for three days to effect repairs.

The investigation established that the accident was a consequence of the car being positioned within the crossing’s danger zone. The investigation could not establish whether this was an unintentional or intentional act.

The investigation also established that the respective mechanical conditions of the car and train did not contribute in any way to the accident. It also established that the train driver operated the train within specified limits and that he responded appropriately when it became apparent that a collision was in prospect.

Whilst emergency services responded efficiently and effectively to the accident, the evacuation of passengers and crew from the train was complicated by a number of the train’s design features. As a consequence of this investigation OTSI made a number of recommendations to RailCorp, the Australian Rail Track Corporation (ARTC) and the Independent Transport Safety and Reliability Regulator (ITSRR).

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Occurrence details

Individual actions Findings Person type Activity type Error/Violation type OTSI found that the collision at the level crossing was the Light passenger Monitoring and Unknown consequence of a failure of the driver of the motor vehicle vehicle driver checking to observe NSW traffic rules 121 and 123. OTSI was unable to determine whether this failure was the consequence of an unintended act (an error), or an intended act (a violation).

Local Condition/Organisational factor Findings Local Keywords Functional area Condition/Organi sational factor There were limited defences to warn drivers of motor Equipment, plant Infrastructure Road vehicles on their approach to the level crossing, or to assist & infrastructure design environment them to remain clear of the rail line when necessary. Design features on the Xplorer, under certain Equipment, plant Functionality Rolling stock circumstances, inhibit emergency egress. & infrastructure construction Additional safety equipment is required aboard services Equipment, plant Availability Rolling stock operated by RailCorp. & infrastructure construction Emergency services were inhibited by a lack of specific Knowledge, skills Emergency Emergency knowledge in relation to emergency access points and & experience operations management power shut-down. knowledge & skills RailCorp’s imposition of blanket speed restrictions Organisational Policy On-train throughout most of regional NSW has reduced the management operations prospect, and consequences, of collisions at level crossings.

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