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Rail Safety Recommendations

This page displays a list of safety recommendations that relate to the rail mode.  You can use the filter tool to refine the results and to search for keywords within the text of each recommendation.

Urgent safety recommendations

Urgent safety recommendations released publicly in advance of a final report are available here until release of a final report at which time they are incorporated into the database.

 

Keywords: Recipient: Mode: Status:

Safety Recommendation 017/17
Issued To KiwiRail on 26 Jun 17
The approval process authorised one person to carry out the rail protection duties for two separate worksites within a protected work area throughout a 52.5-hour track occupation period without appointing a relief rail protection officer. The rail protection officer had worked relatively long hours during the week leading up to the incident and had had no days completely free of work. His working hours had provided limited opportunity for recovery from any fatigue or sleep loss that may have built up, and particularly sleep loss that he experienced on the first night of the planned work.

On 28 June 2017 the Commission recommended that the Chief Executive of KiwiRail review the company's Fitness for Work Policy to ensure that the workloads of personnel undertaking safety-critical work, including staff not on a roster, are managed effectively and that the risk of their suffering from the effects of fatigue is mitigated.
Implementation Status: Open
Reply: KiwiRail confirms that it accepts the intent of recommendation 017/17 and it will now scope the required compliance requirements and undertake the actions required to allow closure of the recommendation. Starting at the corporate level, this will require the implementation of a business-wide policy that will ensure that management control measures are developed and adopted across the business to ensure that personnel performing safety-critical functions have their workloads managed to ensure they don?t potentially suffer the effects of fatigue, which could contribute towards unsafe actions, behaviours or decisions being made.

Safety Recommendation 001/17
Issued To NZTA on 24 Mar 17
The Commission recommends that the Chief Executive of the NZ Transport Agency ensure that in their safety cases the access provider of, and operators using, the National Rail System consider fire in rail vehicles as a risk to the safety of their operations, and must demonstrate that they have mitigated that risk as far as reasonably practicable
Implementation Status: Open
Reply: The Transport Agency confirms that it will implement this recommendation. As it may involve significant work for some operators, the Transport Agency will need to carry out detailed planning to be able to provide the Commission with a definitive timeline. Likely actions include:
- The Transport Agency notifying affected operators
- Safety case variations being requested and approved (if required)
- Conducting a safety assessment of system changes associated with the recommendation, to test that the safety risk is being managed so far as reasonably practicable.

Safety Recommendation 002/17
Issued To NZTA on 24 Feb 17
The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder, ensure that they have identified and assessed the risk of fire in a rail vehicle. The Chief Executive should ensure that they have, as far as reasonably practicable, minimised the risk and have measures in place to deal with the outbreak of, and reactions to, fire events.
Implementation Status: Open
Reply: The Transport Agency confirms it will implement these recommendations. This will occur through our risk based assessment programme. The programme has a 12-18 month cycle to assess all current rail operators, although the Transport Agency will prioritise those that present a greater risk.

The Transport Agency believes that the enduring requirement of fire risk identification and mitigation and assurance is important. We do however note that the priority of rail risks may change over time and it considers that it is essential that the scope and focus of assessments adapts to the current risks and environment identified through the Transport Agency's risk based approach. For that reason it may prove difficult to eventually close these recommendations because of their on-going nature. However, when the Transport Agency has carried out the initial work in respect of all rail operators, we will engage with the Commission to discuss our perspective on how we can continue to gain assurance of the safety outcomes in question.

Safety Recommendation 003/17
Issued To NZTA on 24 Feb 17
The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder operating on the National Rail System, ensure that systems are in place that record in detail the maintenance history of safety-critical rail vehicle parts and that any tests on replacement parts are appropriate to simulate in-service conditions.
Implementation Status: Open
Reply: The Transport Agency confirms it will implement these recommendations. This will occur through our risk based assessment programme. The programme has a 12-18 month cycle to assess all current rail operators, although the Transport Agency will prioritise those that present a greater risk.

The Transport Agency believes that the enduring requirement of fire risk identification and mitigation and assurance is important. We do however note that the priority of rail risks may change over time and it considers that it is essential that the scope and focus of assessments adapts to the current risks and environment identified through the Transport Agency's risk based approach. For that reason it may prove difficult to eventually close these recommendations because of their on-going nature. However, when the Transport Agency has carried out the initial work in respect of all rail operators, we will engage with the Commission to discuss our perspective on how we can continue to gain assurance of the safety outcomes in question.

Safety Recommendation 004/17
Issued To NRSS on 24 Feb 17
The Commission recommends that the National Rail Safety System Executive adopt or develop a New Zealand Fire Standard that incorporates, but is not limited to:
- minimising sources of fire ignition
- restricting fire propagation
- the use of fire-resistant materials
- the provision of appropriate firefighting equipment
- ventilation systems to protect crew and passengers from harmful smoke and gases
- the installation of fixed fire protection systems
- the ability to self-rescue or relocate the train in the event of a fire in a tunnel or similar hazardous location.
Implementation Status: Open
Reply: The NRSS Executive noted that the request to ?adopt or develop? would not be within the scope of the NRSS Executive to undertake, but does recognise that such matters are required to be considered for the operating environment. Therefore the NRSS Executive can propose, through relevant NRSS documentation, the consideration of relevant international standards for the interoperability environment.
These standards would also incorporate, but not be limited to those specific areas as identified by the Commission, due to the systems approaches that will be required to sustain the Commission?s recommendations. The NRSS Executive noted in particular, that rail fire safety is a complex issue and one that requires a system?s approach across all aspects including infrastructure, rolling stock and operations to achieve and sustain safe outcomes.

Safety Recommendation 018/16
Issued To NZTA on 25 Aug 16
On 25 August 2016 the Commission recommended to the Chief Executive of the NZ Transport Agency that he liaise with KiwiRail and relevant road controlling authorities to assess and confirm which provincial level crossings have significant safety issues that do not align with the NZ Transport Agency's Traffic Control Devices Manual - Part 9 - Level Crossings, then work with the authorities to ensure that safety improvements are prioritised and implemented.
Implementation Status: Open
Reply: The Transport Agency, in its capacity as rail safety regulator, will formally write to the appropriate entities, including KiwiRail and advise them of the recommendation 018/16 and request that they advise the Agency of how they plan to:
1. Review the level crossings in their areas to establish if there are safety issues that need addressing - in alignment with the NZ Transport Agency?s Traffic control devices manual - Part 9 - Level Crossings
2. Ensure safety improvements are prioritised and implemented.
We will ensure the Commission is kept informed of the progress made relating to this recommendation.

Safety Recommendation 012/16
Issued To NZTA on 27 May 16
A survey of the Te Onetea Road level crossing was carried out to the ALCAM standards on 20 March 2012. The sighting distances in both directions did not allow sufficient time for long vehicles to drive safely over the level crossing without being struck by a train. Therefore, a fully road-compliant long vehicle could not use the level crossing with the recommended margins for safety.

No action had been taken between the 2012 survey and the date of the accident, 27 February 2014, to mitigate the risk to road users and train vehicles. The Commission recommends that the Chief Executive of the NZ Transport Agency work with KiwiRail and Waikato District Council to address this safety issue.
Implementation Status: Open
Reply: In relation to Recommendation 012/16, the Agency intends to refer the sighting distance issue directly to the Waikato District Council and KiwiRail Holdings Ltd.

We will do this at the earliest opportunity and will report progress back to the Commission.

Safety Recommendation 013/16
Issued To NZTA on 27 May 16
It is possible that the Te Onetea Road level crossing is one that has been affected by changes in the allowable dimensions of long, low road vehicles. Unless the profiles of all level crossings are assessed against the current allowable dimensions for long, low vehicles, the potential risk of this type of accident occurring will remain high.

The ALCAM survey measures the gradient of the road leading up to the level crossing, but does not measure the rate of change in gradient in order to record the profile or vertical alignment of the road for the purposes of ensuring that road-legal vehicles can use the level crossing safely without becoming stuck.

It is important that rail level crossings are compatible with road vehicles, and that road users are made aware of limitations on the use of at-risk level crossings, in much the same way that drivers of high vehicles are warned of low bridges and tunnels.

The Commission recommends that the Chief Executive of the NZ Transport Agency work with KiwiRail and all road controlling authorities to ensure that rail level crossing assessments include a measure of the road profile and compatibility with the allowable dimensions for long and low road vehicles.
Implementation Status: Open
Reply: In relation to Recommendation 013/16, the Transport Agency is currently exploring options of how to best find a solution to addrss this safety recommendation.

We will inform the Commission once the Transport Agency has both determind and can detail the scope of what is required.

Safety Recommendation 001/16
Issued To KiwiRail on 25 Feb 16
The Commission recommends that the chief executive of KiwiRail closely monitor the replacement of brake blocks on individual wagons to provide another predictive tool for preventing premature wheel-bearing failures.
Implementation Status: Open
Reply: We accept this safety recommendation and we are in the process of implementing changes within the business to allow the completion of the required actions. In due course we will provide evidence to demonstrate that the recommended actions have been implemented.

Safety Recommendation 011/15
Issued To KiwiRail on 26 Aug 15
Rail workers are not required to give permission for rail medical officers to access medical records held by their private practitioners, which means the rail medical officers would not necessarily have access to all relevant medical information in order to determine their fitness for safety-critical duties.


The Commission recommends that the Chief Executive of KiwiRail introduce a system whereby KiwiRail medical professionals are automatically granted access to employees' medical records held by private medical practitioners as necessary to ensure employees who perform safety-critical roles are not impaired by prescription or over-counter medications.
Implementation Status: Open
Reply: The new recommendation is considered to be in-line with the other recommendations made in the report, and KiwiRail therefore accepts in principle this recommendation.

In order to achieve the new recommendation, it should be appreciated that other authorities will need to implement changes in order to provide the jurisdiction for allowing the disclosure of medical records held by private medical practitioners to be passed over to KiwiRail medical professionals.

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