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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 012/15
Issued To NZTA on 30 Jul 15
On 30 July 2015 the Commission recommends to the Chief Executive of the NZ Transport Agency that from a regulatory perspective he take the necessary steps to ensure that the relevant Safety Case(s) and resultant safety system(s) (including any lease or access agreements made under those systems) expressly articulate which party or parties is responsible for controlling and protecting pedestrians as they cross the boundaries between railway stations and the rail corridor.
Implementation Status: Open
Reply: While the Transport Agency gives the Commission an undertaking to implement this recommendation, we must first consider the statutory and regulatory options in which to do this. This will involve engaging with a number of relevant parties - a process that will take time. We will advise the Commission of our progress in due course.

Safety Recommendation 013/15
Issued To NZTA on 30 Jul 15
On 30 July 2015 the Commission recommends that the Chief Executive of the NZ Transport Agency liaise with the relevant road control authorities in Auckland and Wellington, and KiwiRail, to review all pedestrian rail crossings and ensure that they address the safety issue whereby they have a level of protection commensurate with the level of risk currently and in the immediate future.
Implementation Status: Open
Reply: Throughout New Zealand, a wide range of level crossing-related activities and work is being undertaken by a variety of rail participants and agencies. This work encompasses level crossing infrastructure, planning, funding, risk review and risk mitigation.

Consequently, the Agency is commencing a ?stock-take? of this work and the parties responsible for it to give us a greater knowledge base about the solutions being developed and by whom. When this work is completed and the Transport Agency has a comprehensive picture of the scope of activities underway, it will be in a clearer position to provide the Commission with information about this recommendation.

Safety Recommendation 008/15
Issued To MoT on 28 May 15
There is no requirement for health professionals who provide primary health care to transport industry personnel employed in safety-critical roles to inform appropriate authorities when there are concerns regarding the fitness of duty of such personnel under their care. In this instance the driver had been prescribed a collection of medications that singularly or collectively had the potential to adversely affect his performance, yet he continued to drive freight and passenger trains.


The Commission recommends that the Secretary for Transport address this safety issue.
Implementation Status: Open
Reply: The Ministry of Transport will consider the implications and options. It will work with the NZTA and the rail industry in looking at options for addressing the intent of this recommendation.

Safety Recommendation 005/15
Issued To NZTA on 26 Mar 15
Rail Standards for New Trains

The National Rail System Standards (6) (Engineering and Interoperability) is the only standard within the National Rail System set that defines braking performance. However, it does not address the performance in low adhesion conditions of modern metropolitan passenger trains that are fitted with computer controlled brake and wheel slide protection systems. The current National Rail System Standard (6) does not require any more from a braking system than for a train to be able to stop within a specified distance in dry conditions.

The regulator for the country of operation or the purchaser may define what adhesion conditions might be encountered on a rail network and what level of braking performance is expected from a new train and what standards the train is to be tested to for compliance. This is also the stage in commissioning a new train, when the interaction between all of the brake systems is adjusted to achieve the optimum overall brake performance. The Rail Safety and Standards Board in UK have produced a Guidance Note (GM/GN2695) to achieve this purpose in the UK but nothing similar exists for New Zealand.

The Matangi train brake systems were tested for compliance and proper operation, but they were not tested and adjusted for optimum brake performance in low adhesion conditions.

In Wellington, where new trains were commissioned into service with computer controlled braking and wheel slide protection systems, but that the complete train braking systems were not optimised to achieve the most effective brake performance in low adhesion conditions. The Commission considers that the occurrences in Wellington may be repeated unless the National Rail System standards are revised.

As a minimum the Commission considers that the National Rail System standards should call upon appropriate international standards to formalise new train type testing and ensure that train braking systems are tested in low adhesion conditions and optimised for the train.

The Commission recommends that the Chief Executive of the New Zealand Transport Agency require a full review of the National Rail System standards, and in particular standard No. 6, to ensure that low adhesion braking requirements are defined in the standards and made applicable for all trains intended to operate on the National Rail System.
Implementation Status: Open
Reply:

Safety Recommendation 006/15
Issued To NZTA on 26 Mar 15
Auckland Trains

The Commission is aware that new passenger trains have recently been introduced in Auckland. The Commission is not aware of any safety issues with the new trains but expects they would have been tested to comply with the same National Rail System standards as the Matangi trains in Wellington. Therefore, they may be exposed to the same lack of optimised brake performance risks in low adhesion conditions.

The Commission recommends that the Chief Executive of the New Zealand Transport Agency review the process followed for the commissioning of the Auckland trains, and if they have not been optimised for low adhesion conditions or adhesion management systems introduced to reduce the risk of incidents across the network, he address those safety issues in line with the safety actions planned for the Matangi train operation."
Implementation Status: Open
Reply:

Safety Recommendation 023/14
Issued To NZTA on 19 Nov 14
The train controller had been identified by KiwiRail management as having concentration and focus issues in relation to tasks required for the safe execution of track occupation authorities following a track occupation irregularity during February 2012. This was 16 months before the track occupation irregularity covered in this report, and during that period the train controller went on to have two further operating irregularities while he remained in the role.

The Commission recommends to the Chief Executive of the NZ Transport Agency that he address with KiwiRail the safety issue whereby KiwiRail's standard policy and procedures allowed an "at-risk" train controller to continue working at train control workstations while undergoing a formal investigation and remedial process after KiwiRail had identified issues that would have affected his ability to perform his safety-critical role effectively.
Implementation Status: Open
Reply: Recommendation 023/14 that the Commission has directed to the Chief Executive of the NZ Transport Agency is accepted. Discussions on this recommendation will be initiated on the publication of the final report. These discussions will include a projected timeframe for implementation. This will be advised to the Commission in due course.

The NZ Transport Agency has commenced the process for a Special Safety Assessment of KiwiRail's National Train Control Centre (NTCC) to be conducted, starting on Tuesday 20 January 2015. This will enable the Agency to have a greater level of insight into the NTCC operation to ensure that the licensed operator is operating within the requirements of its safety case.

Safety Recommendation 022/14
Issued To KiwiRail on 29 Oct 14
KiwiRail's Risk Management Policy for "continuity of core services" did not give proper consideration to the safety of passengers and crew when a core service such as train control failed, causing the widespread stoppage of an entire metropolitan passenger rail system.

On 29 October 2014 the Commission recommended that the Chief Executive of KiwiRail revise the risk rating assessment matrix in its Risk Management Policy to reflect the fact that train control is a safety-critical service, and to consider the safety of people in crowds when assessing and mitigating the risks.
Implementation Status: Open
Reply: KiwiRail have considered the recommendation and respond as follows:

-The KiwiRail risk matrix, which forms part of KiwiRail's risk management policy, applies across all business units and is designed to provide guidance when assessing many different types of risk for the business.
- The risk matrix provides a consistent methodology that can be applied across different business units and types of risks.
- When assessing a risk, the person or project team responsible must consider the context of the risk; the various consequences that may arise should a risk materialise, and the impacts of those consequences. As there may be multiple potential consequences, the consequence with the highest degree of impact should be used as the factor when determining the overall risk rating. Failure to do this may underestimate the level of risk exposure.
- The Commission have identified that although the initial project team used the risk matrix in order to determine the risk rating, the risk was evaluated based on the impact of continuity of core services being compromised as opposed to potential safety impacts.
- Rating the risk based only on the impact of continuity of core services resulted in the risk not receiving the required level of management attention. Had the risk been evaluated on the basis of potential adverse safety impacts, the risk would have been rated higher and therefore received the required degree of management attention.
- It is KiwiRail's view that the risk matrix did not contribute to the failure to identify train control as a business critical risk. Rather, the consequences of the risk were not adequately identified resulting in the risk not being assessed against potential safety consequences on the matrix. This resulted in a risk rating lower than it should have been.
- A Risk Management Manual was developed in July 2013 to provide guidance to KiwiRail business units in their assessment of risks and the application of the risk matrix. The Risk Management Manual highlights the need to assess all potential consequences and that the highest degree of impact should be used as the factor when determining the overall risk rating. The manual had not been released at the time this incident occurred. It is available to all staff on the KiwiRail intranet and risk assessment practices have improved significantly since this incident occurred.

Safety Recommendation 019/14
Issued To KiwiRail on 01 Jul 14
The Commission further recommends that KiwiRail assess all other terminating stations on the controlled network throughout New Zealand and similarly apply permanent speed restrictions as necessary to the approaches at those stations.
Implementation Status: Open
Reply: General Manager - Rail Passenger Group advised that KiwiRail had "completed a risk assessment for all lines in the metro Wellington region that have no over-run (end of line) with stop blocks to establish that the controls in place are appropriate for managing approach speeds and distances to the stop blocks in the event that there is a similar [occurrence] caused by lack of braking action, and that any resultant impact damage would be adequately contained".
As a result of the risk assessment, "a 25 km/h speed restriction has been placed on the Johnsonville Line, similar to that which has been introduced for the Melling Line".

Safety Recommendation 008/14
Issued To KiwiRail on 17 Mar 14
None of KiwiRail's staff involved with loading and securing the wagon body was sufficiently familiar with the KiwiRail Freight Handling Code to realise that the securing arrangement was not compliant with the Code.

KiwiRail had a responsibility to ensure that staff was trained and competent in all tasks being undertaken. It had to ensure that the loading and stowage of goods on railway wagons were carried out by people with the appropriate training and certification.

The Commission recommends that the Chief Executive of KiwiRail take steps to ensure that appropriate training is given to all staff involved in load security and that staff responsible for checking load security at the various stages of a train journey are discharging their duties in a manner consistent with the KiwiRail Freight Handling Code.
Implementation Status: Open
Reply: KiwiRail intentds to take the following actions:

1. KR Operational and Training Manager have been tasked to carry out a Training Needs Analysis (TNA), develop and implement a KR Training package to designated KR Staff (Freight Terminals) and Third Parties (Freight Staff).

Individual type Training Packages are to ensure that all staff involved in loading, load security certifying load, accessing presented load, responsible for checking load security at the various stages of a train journey are discharging their duties in accordance with the Freight Handling Code.
- Training Needs and Analysis (TNA) is envisioned for a completion date 31 May 2014.
- Training Development is envisioned for a completion date 31 Jul 2014
- Training Delivery programme is envisioned for completion date 30 Sep 2014

2. KiwiRail will discuss with Third Parties on how best to scope and undertake the training: however whilst in infancy development and the catch-all and confidence assurance to KiwiRail will be 1 above.

3. For Audit purposes the "Training Programme" is to electronically record the individual?s course completion, competency/authorisation and ongoing refresher training requirements. Third Party Facilities to self-manage staff competencies post course completion notification (KiwiRail/Internal) Refer 5 below.

4. KiwiRail Freight Operations will develop an en-route monitoring programme to ensure cargo remains appropriately secured and fit to travel. Special Project to be completed by 30 Sep 2014. Refer 5 below.

5. KiwiRail Audit will develop and audit and revalidation programme to support 1 and 2 above.

Safety Recommendation 009/14
Issued To NZTA on 17 Mar 14
No-one involved with loading, shifting and securing the wagon body was sufficiently familiar with the KiwiRail Freight Handling Code to realise that the securing arrangement was not compliant with the Code.

KiwiRail had a responsibility to ensure that staff was trained and competent in all tasks being undertaken. It had to ensure that the loading and stowage of goods on railway wagons were carried out by people with the appropriate training and certification.

The Commission has recommended that the Chief Executive of KiwiRail take steps to ensure that appropriate training is given to all staff involved in load security and that staff responsible for checking load security at the various stages of a train journey are discharging their duties in a manner consistent with the KiwiRail Freight Handling Code.

It is important that KiwiRail address the above recommendation, which addresses the safety issues examined in the report. The NZ Transport Agency has various powers under the Railways Act 2005 to monitor and ensure KiwiRail?s performance and compliance.

The Commission recommends that the Chief Executive of the NZ Transport Agency ensure that KiwiRail addresses the above recommendation.
Implementation Status: Open
Reply: Recommendation 008/14 that the Commission have directed to the Chief Executive of KiwiRail is noted.

Recommendation 009/14 made to the Chief Executive of the the NZ Transport Agency is accepted.

Discussions on these recommendations will be initiated on the publication of the final report. These discussions will include a projected timeframe for implementation. This will be advised to TAIC in due course.

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