Executive summary
On Friday, 6 September 1996, at about 0200 hours, P35 Shunt operated by Tranz Rail Limited was shunting in Palmerston North Yard. During a propelling movement to place wagons the shunter fell under the wagons and was killed instantly. Safety issues addressed in the report are the frequency of shunting fatalities, and the effectiveness of compliance monitoring of recently certified and relatively inexperienced staff.
Related Recommendations
Formally structure compliance monitoring for newly-appointed staff to include input from experienced shunting staff where appropriate.
Review procedures for compliance monitoring of shunting staff to place more emphasis on an increased level of "unannounced" observation of staff during normal duties and less emphasis on "arranged" monitoring by training staff.
Use a more continuous compliance monitoring regime to ensure that newly-appointed staff are consistently using work practices which do not place them, or others, at unacceptable risk before they are certified for shunting duties.
Redraft the instructions currently in Section 5, clause 1.8, of the Operations Code, to make it clearer under what conditions "absolute necessity" applies when considering the option to signal the movement from a position on the ground.