Executive summary
On Wednesday, 24 May 1995 at about 0820 hours Q2 Shunt operated by New Zealand Rail Limited was shunting at Gracefield yard. During a propelling movement to attempt to catch and hook onto a moving wagon, the Rail Operator riding on the leading wagon fell under the Shunt and was killed instantly. Causal factors were unauthorised shunting procedures, wagon drawbar condition, limited experience of staff and effectiveness of compliance monitoring. Safety deficiencies addressed in the report are the suitability of and compliance with instructions covering loose shunting. Safety issues addressed in the report are the suitability of and compliance with procedures for wagon inspection and repair, and the training and certification of Operating staff.
Related Recommendations
Review the adequacy of Local Instructions covering shunting for all localities, with particular regard to loose shunting.
Urgently review the adequacy of the existing Local Instruction covering shunting at Gracefield to ensure it clearly defines under what circumstances, if any, loose shunting is allowed with a two man gang.
Carry out specific training and educational programmes to make all yard operational staff fully aware of the requirements for loose shunting and institute a system to ensure compliance.