Executive summary
At approximately 0700 hours on Friday, 1 October 1999, a rail operator fell from a slow moving wagon during shunting operations at Stillwater, when a handgrip detached as he was boarding the wagon. The rail operator fell backwards away from the wagon and landed alongside the track, sustaining minor injuries as a result.
The safety issues identified included:
• the inability of the inspection regime to identify the defective handgrip
• the unreported damage to, and unauthorised reinstatement of, handgrips arising from load handling and inappropriate shunting methods
• the susceptibility of repair welded handgrips to sudden failure
• the control of shunting in rail sidings.
Four safety recommendations were made to Tranz Rail Limited, and three to the Land Transport Safety Authority, to address these issues.
[The 3 safety recommendations to the LTSA were reaffirmed as a result of the Commission's investigation into another incident at Stillwater on 13 September 2001. Refer report 01-112.]
Related Recommendations
Introduce operating procedures for Tranz Rail staff and customers who move wagons without using rail mounted vehicles, or load or unload wagons, which ensure: only approved equipment is used, and only by appropriately certified staff; equipment for moving wagons is applied at approved positions, and that these positions are clearly defined to staff concerned; that any damage causing deformation to safety critical components such as handgrips which could compromise fitness for purpose is identified promptly and the wagons removed from service.
Improve methods of identifying rail siding operators and ensure that all identified operators are licensed or exempted as appropriate.
Ensure that licensed rail siding holders have an approved operating plan that includes appropriate training and procedures to minimise damage to safety critical wagon components.
Introduce standards for design, inspection and repair of safety critical components which ensure they remain fit for purpose in the intended operating environment.
Take immediate steps to control the weld repair of safety critical components to recognised standards to ensure the integrity of the original installation is retained.
Undertake an immediate inspection of all wagons utilizing this type of handgrip and remove from service those showing evidence of straightening and welding which could adversely effect the integrity of the handgrip and its fitness for purpose.
Ensure that exemptions are only granted when LTSA is satisfied that operating methods meet approved criteria.