Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Either immediately prohibit the public use of the level crossing in accordance with Clause 1(d) of the Deed of Grant or, if public use is to continue, give written consent to the lessee under conditions which ensure safe public access.

There were discrepancies between the Rail Operating Rules and Procedures, the Rail Operating Code, the Conveyance of Dangerous Goods Code Supplement and the National Rail System Standard in how to respond to a derailment involving empty LPG wagons and staff were not appropriately trained and familiar with the correct procedures to follow.

On 24 August 2017, the Commission recommended that the Chief Executive of KiwiRail review its post-incident drug and alcohol policy to ensure that all personnel directly involved in an accident and/or operating incident are asked to submit to testing.

Review the likely safety benefits of the installation of suitable carbon monoxide detection devices in the cabins of aircraft which have potential for an ingress of carbon monoxide, with a view to making the installation of such devices mandatory in appropriate circumstances.

Liaise with the Christchurch City Council to review the integrated use of Barters Road and Kirk Road level crossings and take such steps as are necessary to encourage long vehicles to use Barters Road level crossing and to prohibit any uncontrolled crossing of Kirk Road level crossing by vehicles exceeding 11 m in length.

Control the conditions for cab riders to avoid familiarity resulting in a delegated control function.

introduce the formalised crew resource management procedures recommended in safety recommendation number 001/99, and ensure that such procedures include remote-control operators operating main line shunts.

By the most appropriate means ensures that all skippers and crew members within the safe ship management system are advised and instructed on the importance to safety of good "housekeeping" within the engine room spaces and that all repairs and modifications should be carried out using appropriate materials to the satisfaction of a safe ship management surveyor.

The train driver in this instance had several weeks earlier received a radio call about a divergent path to bypass a disabled passenger train at Otahuhu. However, on this occasion he did not receive a similar radio call warning him that his train was not going to follow the usual path. The circumstances of this latest accident provide further evidence that additional advice to train drivers about conditions that are likely to affect their trains can help to prevent accidents.

The development of Project Kupe system has the potential to reduce the risk of collision on the network but, due to resource and funding restraints without a cost/safety benefit analysis being undertaken, the project has extended out by 2½ years and has still not been approved. The Commission recommends the New Zealand Transport Agency takes action to address the safety issue (004/09).

Implements procedures to assure compliance with the rules for securing detached wagons left on the main line.

install a protection device on the Onehunga industrial line near Owen’s Siding to prevent uncontrolled wagon movements in a westerly direction beyond that point.