Executive summary
At about 0702 hours on Wednesday, 20 October 1999 Train 938, a northbound express freight, collided with Train 919, a southbound intercity express freight, which was stationary on the main line within station limits at Waipahi on the Main South Line.
The locomotive engineer of Train 919 was fatally injured, and the locomotive engineer of Train 938 was seriously injured.
The two locomotives on Train 919 and the single locomotive on Train 938 were extensively damaged, as were a number of wagons and containers.
Causal factors included one locomotive engineer’s misunderstanding of his track warrant limit and the limited effectiveness of the action taken by the operator and the regulator to minimise the possibility of such misunderstandings.
Recommendations were made to the operator and the regulator to address the safety issues identified.
[The following paragraph was added by addendum finalised on 7 December 2001.]
Following the publication of Railway Occurrence Report 99-122 the Commission received additional information based on a new recorded departure time of Train 919 from Clinton. This strengthened some previously expressed concerns at the interpretation which could be placed on sections of the report covering actions open to the locomotive engineer of Train 919 (LE 2) on the day. The Commission considers the new information does not affect the findings and recommendations of the report, but does warrant this addendum to clarify the time restraints applicable to Train 919 and LE2.
Related Recommendations
undertake a comprehensive zero-based revision of the TWC Regulations (and their associated practices) to ensure that adequate defences are in place to combat foreseeable risks arising out of human error.
decide whether flexible interpretation of Regulation 10(b)(i) by other than train control is to be permitted, and if so amend the regulations and introduce procedures to control any exceptions.
Amend the rules for working Warrant Stations to require all crossing trains, whether berthing on the main line or the loop, to establish the whereabouts of the opposing train before entering the appropriate main line or loop
Introduce a procedure for endorsing Track Warrants with the time and train number associated with radio calls made to establish the whereabouts of opposing trains prior to crossings, and ensure it is audited.
take note of staff perceptions and experiences revealed by interviews carried out during this investigation and put processes in place, including regular personal familiarisation with operating practices, to improve corporate safety culture and its understanding at field level.
Immediately prohibit the issue of conditional track warrants to the locomotive engineers of trains which are awaiting a crew change.