ONRSR deploys its investigative resources in order to establish whether a breach of the Rail Safety National Law (RSNL) has occurred.
An investigation is a formal, detailed and compliance focused examination of the circumstances and operators’ actions associated with an occurrence or safety issue. An investigation to establish whether a breach of the RSNL has occurred may be conducted in response to a range of circumstances including but not limited to:
ONRSR will always carry out a site investigation of a reportable work-related death, unless there are other specific reasons for not doing so, in which case those reasons will be recorded.
ONRSR has produced a definitive visual guide covering how our national investigations team works and what operators and rail safety workers should expect when interacting with them.
Click on the video link below to watch.
In selecting which complaints or reports of incidents or injury to investigate, and in deciding the level of resources to be used, ONRSR will take account of the following factors:
ONRSR will investigate in order to determine:
In Australia, investigations into incidents on the rail network are a shared responsibility between national, federal, and state-based agencies, each of which has a separate but complementary role to play in improving rail safety.
Depending on the circumstances of an incident, separate investigations may be conducted by an independent ‘no-blame’ safety investigator, the rail safety regulator, a work health and safety regulator, relevant police, and/or the coroner.
Regulatory investigations are carried out by the Office of the National Safety Regulator (ONRSR) under the Rail Safety National Law.
Independent ‘no-blame’ rail safety investigations are undertaken by the following agencies:
The ATSB operates under the Commonwealth Transport Safety Investigation Act 2003 (TSI Act). OTSI and OCI are governed by NSW and Victorian legislation, respectively, but to promote consistent no-blame investigative practices across Australia, a collaboration agreement between the three agencies enables OTSI and OCI to conduct investigations under the TSI Act using ATSB processes.
This agreement facilitates the consistent use of legal instruments by the three agencies, a common investigation methodology and a common report structure and style.
OTSI and OCI conduct most of their rail investigations under the TSI Act but retain State powers to investigate outside the collaborative arrangements with ATSB and this may occur from time to time. This is made clear to involved industry parties at the time of investigation.
Both regulatory and independent no-blame investigations examine serious or significant incidents to understand what happened and why, with the aim of enhancing rail safety, but there are key differences.
Regulatory investigations
ONRSR investigates rail safety incidents to identify if any actions are required to address immediate safety concerns, if risk controls implemented by operators were effective, and if there have been any breaches of the Rail Safety National Law. The information gathered is also used to inform operators across rail sectors or the whole industry, where these safety issues apply, of potential limitations or concerns.
The Regulator will examine whether the processes and procedures required of all parties in the operation of a railway have been properly established, monitored and adhered to, and importantly, if they are effective in managing risks to safety.
As a result of an investigation, ONRSR may take compliance action ranging from issuing improvement notices through to prosecution and suspension of an operator’s accreditation - if there is an immediate and serious risk to safety.
ONRSR provides advice and guidance to operators to support their compliance with the Rail Safety National Law.
No-blame investigations
The ATSB, OTSI and OCI investigate to prevent future incidents by ensuring lessons are learned and safety improvements are made by the relevant parties including rail infrastructure managers, rolling stock operators, the broader industry, government agencies and regulators.
Publishing and promoting investigation reports and findings provides transparency to the public and ensures learnings are shared with the wider rail industry.
The ATSB, OTSI and OCI are independent of rail transport operators and regulators. They are unconstrained by conflicts of interest in being able to investigate and report on factors increasing risk that might be found across the safety system. They do not seek to apportion blame to specific operators or individuals.
Investigation scope will vary depending on the incident but can be broad and may also include examination of the role of rail safety regulation.
The roles and functions of the ATSB, OTSI and OCI do not include taking regulatory or criminal action. These functions reside with regulatory and enforcement agencies.
The TSI Act guards against evidence being inappropriately used in court or regulatory proceedings. For example, no blame investigation agencies do not disclose sensitive witness statements.
No blame investigations will often focus on matters where there are likely to be systemic safety issues and safety messaging of benefit to large sections of the industry.
Accredited rail transport operators must report certain rail safety incidents (‘notifiable occurrences’) to ONRSR within set timeframes. Operators may also choose to report incidents directly to the ATSB, OTSI and OCI.
Operators must report the most serious incidents (‘Category A’) to ONRSR immediately and ONRSR supplies this information directly to the ATSB, OTSI and OCI.
Nationally, ATSB provides a confidential reporting service through REPCON. Additionally in NSW, safety incidents or concerns can be confidentially reported by any person via OTSI’s Confidential Safety Information Reporting Scheme.
Rail Safety Officer - Investigators have various powers under the Rail Safety National Law (RSNL) to compel the production of documents and to require answers to questions for the purposes of investigating suspected contraventions of the RSNL.
Operators and rail safety workers are encouraged to read the sections of RSNL quoted below in full via the Related Content link on the right-hand side of this page.
The three primary ways to compel information are:
A Rail Safety Officer - Investigator may at any time enter a place that is, or that the office reasonably suspects, railway premises.
A Rail Safety Officer - Investigator who enters a place under section 143 may do any of the following:
(a) inspect, examine and make inquiries at the place;
(b) inspect and examine any thing (including a document) at the place;
(c) bring to the place and use any equipment or materials that may be required;
(d) enter or open, using reasonable force, rail infrastructure, rolling stock, a road vehicle or other thing to examine the rail infrastructure, rolling stock, road vehicle or other thing;
(e) give directions with respect to the stopping or movement of any rolling stock or road vehicle;
(f) take measurements, make surveys and take levels and, for those purposes, dig trenches, break up the soil and set up any posts, stakes or markers;
(g) conduct tests and make sketches or recordings (including photographs, films, audio, video, digital or other recordings);
(h) mark, tag or otherwise identify rolling stock, a road vehicle or other thing;
(i) seize any thing (including a document) at the place if the officer reasonably believes the thing is evidence of an offence against this Law;
(j) take and remove for analysis, testing or examination a sample of any substance or thing without paying for it;
(k) require a person at the place to give the officer reasonable help to exercise the officer's powers under paragraphs (a) to (j);
(l) exercise any power that is reasonably necessary to be exercised by the officer for the purposes of this Law.
(1) For the purpose of protecting evidence that might be relevant for compliance or investigative purposes, an authorised officer may secure rolling stock or the perimeter of any site at a place by whatever means the authorised officer considers appropriate.
(1) A Rail Safety Officer - Investigator who enters railway premises under section 143 may seize anything (including a document) at the premises if the officer reasonably believes the thing is evidence of an offence against this Law.
(1) To enable a thing to be seized under this Part, a Rail Safety Officer - Investigator may direct the person in control of it—
(a) to take it to a specified place within a specified time; and
(b) if necessary, to remain in control of it at the specified place for a period specified in the direction.
Following a rail safety incident, the regulator may issue a rail transport operator with a Notice to Conduct an Investigation under s122 of the RSNL - requiring the operator to undertake an investigation into the occurrence.
This may occur because ONRSR is concerned:
The notice will typically set out the:
The RTO retains the ability to investigate the incident in a broader nature and in line with its safety management system. The onus remains on the RTO to identify and rectify safety issues that are identified through the investigation.
It is important that the final investigation report provided to ONRSR addresses all the matters outlined in the scope of the notice. If the investigation report is incomplete it is likely further requests for information will be made or compliance activities undertaken.
Further guidance on what ONRSR expects from industry investigation reports is provided in the Investigation Reports by rail transport operators Guideline.
The findings and recommendations will be examined to gain a better understanding of the incident and how the RTO is managing safety. ONRSR may use the investigation report to inform its audit and inspection activities for the individual RTO(s) involved in the incident or at a broader industry level.
The information contained in the investigation report provided under a notice cannot be used by ONRSR as evidence against the RTO in civil or criminal proceedings (other than proceedings arising out of the false or misleading nature of the information or document).