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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 002/12
Issued To NZTA on 28 Mar 12
The Commission recommends to the Chief Executive of the NZ Transport Agency that he requires the Executive of the National Rail System Standard to develop standards to ensure that all rail participants meet a consistently high level of crew resource management, and communication that includes the use of standard rail phraseology (002/12).
Implementation Status: Open
Reply: We intend to work closely with the National Rail System Standard (NRSS) Executive with an aim to implementing and closing out this recommendation as soon as practicable. The NZ Transport Agency sits of the NRSS Executive as an observer. We will also consider a strategy for rail operators outside the NRSS coverage.

Safety Recommendation 030/11
Issued To NZTA on 16 Dec 11
The distance between the compulsory stop line and the rail corridor at the Beach Road level crossing at Paekakariki is 10.5 m. The bus involved in this accident was 12.6 m long. Many other buses and various configurations of trucks are longer than 10.5 m. This means that when one of these long vehicles stops at the stop sign (as it is required to do) the back of the vehicle will foul the rail corridor and be at risk of being struck by a train. Technically then, any such vehicles intending to turn right to State Highway 1 cannot comply with the road rules when using this level crossing. Any long vehicle would be at risk of being struck by a train when waiting at the stop sign for a break in the traffic travelling on State Highway 1. Additionally, there is no signage at the level crossing warning drivers of long vehicles that there is only a 10.5 m stacking distance.

The Commission recommends to the Chief Executive of the NZ Transport Agency that as a matter of urgency he address this safety issue.
Implementation Status: Open
Reply: The stacking distance issue applying to right turning traffic exiting/entering Beach Road from State Highway One [one] is acknowledged. However a solution to this is problematic.

Restriction of turning movements out of Beach Road is not favoured by the Kapiti Coast District Council. However, the prohibition of right turns out of Hill Road would simplify movements at the intersection and might aid right turns out of Beach Road. This option will be investigated further.

Installation of traffic signals is a high cost option requiring land acquisition. Although this is favoured by the Kapiti Road District Council, it has the potential to impose significant delays on the State Highway resulting in queuing and the potential to increase the collision risk. The current crash record at the intersection is low and it is likely that this option would increase it.

Further to the above, the NZ Transport Agency has been advised by the Greater Wellington Regional Council that it [the Council] is considering the mandating of shorter buses at the Beach Road level crossing.

Safety Recommendation 033/10
Issued To MoT on 19 Aug 10
It was recommended to the Secretary for Transport that he address the status of the National Rail System Standard and the relationship between these standards and rail participants' safety cases and underlying safety systems is not clear. For example, it is not clear whether KiwiRail's safety case and its underpinning safety system can be required to comply with the NRSS as a minimum, or whether the NRSS is subservient to KiwiRail's safety system. An approved (by the regulator) change to KiwiRail's safety system could then by default become an approved change to the NRSS. If the latter, then it is also unclear what the relationship between the NRSS and other rail participants' safety cases and underpinning safety systems would be.
Implementation Status: Open
Reply: As the National Rail System Standards are industry standards, which are developed by the NRSS Committee, and approved for inclusion in a rail operator's safety case by the regulator, the Ministry is well placed to carry out an independent review. In carrying out this review, the Ministry will particularly focus on the matters raised in recommendations 033/10 and 034/10.

Safety Recommendation 034/10
Issued To MoT on 19 Aug 10
It was recommended to the Secretary for Transport that he address the following safety issues: The status of the NRSS Committee, the rights to membership of that committee and the responsibilities of each Committee member, and the terms of reference of the Committee is currently unclear. (034/10)
Implementation Status: Open
Reply: As the National Rail System Standards are industry standards, which are developed by the NRSS Committee, and approved for inclusion in a rail operator's safety case by the regulator, the Ministry is well placed to carry out an independent review. In carrying out this review, the Ministry will particularly focus on the matters raised in recommendations 033/10 and 034/10.

Safety Recommendation 035/10
Issued To MoT on 19 Aug 10
the National Rail System Standard has not been fully reviewed since they were established in 2004. Once the status of the standards and its Committee has been established then an independent review of the standards should be conducted to determine if they are still applicable to the New Zealand rail industry, and to ensure if they are representative of standards set in other comparative countries operating modern rail systems.
Implementation Status: Open
Reply: The Ministry accepts this recommendation

Safety Recommendation 017/10
Issued To NZTA on 21 Jul 10
Standards for maximum working hours and minimum rest periods on the train control roster could result in a train controller being fatigued at the start of a shift even in the absence of any other fatigue-inducing factors. The train control roster policy including, but not limited to, standards for maximum working hours and minimum rest periods should be reviewed to ensure it is designed to mitigate fatigue and promote wellness.
Implementation Status: Open
Reply: We intend to work closely with KiwiRail with an aim to implementing and closing these recommendations as soon as practicable.
Discussion on them will commence on the publication of the report and will be ongoing. Any outstanding Transport Accident Investigation Commission (TAIC) recommendations also form an integral part of our annual safety assessments of the rail industry.
When these discussions are concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing these safety recommendations.

Safety Recommendation 029/09
Issued To NZTA on 19 Aug 09
The current track and mechanical code standards and maintenance tolerances are not compatible and there remains a high risk of derailments caused by dynamic interaction.
Implementation Status: Open
Reply: We intend to work closely with KiwiRail with an aim to implementing and
closing these recommendations as soon as practicable.

Safety Recommendation 010/05
Issued To Toll NZ Consolidated on 04 Apr 05
In conjunction with New Zealand Railways Corporation critically review current track and mechanical code standards and maintenance tolerances to ensure they are compatible and minimise the potential for derailments caused by dynamic interaction.
Implementation Status: Open
Reply: We accept this recommendation. A similar recommendation has been raised during the joint internal investigation into a similar incident and has been accepted by Ontrack and Toll Rail management.

Safety Recommendation 094/04
Issued To Toll NZ Consolidated on 08 Mar 05
Introduce a regime to provide unique identification of each bogie to enable the tracking of its operational and maintenance history.
Implementation Status: Open
Reply: For the last few years, both Hillside and Hutt workshops have been marking and recording serial numbers on bogies when they are overhauled. Subsequently we can trace when and where a bogie was last overhauled if it is involved in an incident. However it will be several years before all bogies have gone through a workshop for overhaul, to have a serial number assigned.

We are not recording which wagons these serialised bogies are going into, although bogies are checked at a two-yearly C-check and also whenever a bogie is swapped. At this time bogie wear limits are programmed into Alstom?s computer system, which creates alerts for more regular checks as the bogie nears its limit.

As bogies are changed based on condition (rather than kilometres travelled or time in service), we are unsure how the serialisation of bogies would help prevent a similar incident.

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