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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:

  • a notifiable occurrence;
  • an adverse finding from an audit;
  • outcomes identified from an inspection;
  • outcomes identified from an investigation;
  • matters identified by trend analysis;
  • findings from a rail transport operator’s investigation report;
  • confidential or other intelligence reports; or
  • a written direction from a responsible Minister on a rail safety matter relating to a specific jurisdiction.

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.

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:

  • the severity and scale of potential or actual harm;
  • the seriousness of any potential or actual breach of the law;
  • knowledge of the RTO's past performance in terms of compliance with the law;
  • ONRSR’s enforcement priorities;
  • the likelihood of the investigation leading to successful enforcement action against a RTO or a meaningful improvement in its behaviour; and
  • the wider relevance of the event, including serious public concern.

ONRSR will investigate in order to determine:

  • the causes and whether there has been a breach of legislation;
  • whether action has been taken or needs to be taken to prevent a recurrence of an incident and/or to secure compliance with the law;
  • lessons to be learnt and whether there is a requirement to influence the law and industry guidance; and
  • what response is appropriate to a breach of the law.

The Australian Transport Safety Bureau (ATSB) is responsible for identifying the causes of accidents it investigates in order to improve safety; it does not allocate blame.

Working arrangements agreed between ONRSR and the ATSB reflect both their respective statutory duties and the need to ensure efficient and effective liaison. ONRSR and the ATSB have a Memorandum of Understanding in place.

s122 Investigation

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:

  • about the rail incident that occurred;
  • that the incident is reoccurring within the individual RTO’s operations or within the rail industry; or
  • that the RTO has not undertaken an adequate investigation into the incident or considers it necessary to set the scope for the investigation.

The notice will typically set out the:

  • terms of reference for the investigation to ensure that the RTO’s investigation will take into consideration the matters that are of concern;
  • timeframe for the investigation, noting that there are penalties applicable under the RSNL for failing to meet the timeframe – ONRSR may consider extensions for genuine reasons; and
  • requirement to provide the investigation report to ONRSR.

What is required of the operator?

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.

How is the report used?

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).

Last updated: Oct 8, 2021, 10:21:06 AM