Executive summary
On 17 December 1999, an incident occurred near Greymouth where a locomotive engineer was given permission by train control for his train to enter a section of track already occupied by a hi-rail vehicle. The driver of the hi-rail vehicle saw the train and was able to off-track in time to avert a collision.
On 17 January 2000, train control gave permission for a group of hi-rail vehicles to on-track near Paerata in front of a passenger express train. The train collided with one of the hi-rail vehicles and pushed it some 300 m along the track. The hi-rail vehicle, which was unoccupied at the time, was destroyed in the collision.
Another 2 incidents occurred where train control gave permission for trains to enter sections of track occupied by hi-rail vehicles: one on 14 February 2000 near St Andrews, and one on 5 September 2000 near Woodville. Neither of these 2 incidents resulted in collisions.
Given the similar issues arising from each incident, all 4 were combined into this one report.
Safety issues identified included:
• the repeated non-adherence to basic train control techniques taught during training and covered by procedures in the operating code
• inadequate auditing and assessment of train controller performance
• train controllers not using, nor being required to use, signal "blocking commands" as a defence against them issuing conflicting instructions to track users
• the potential for train controllers to report for duty when not fit to do so.
Four safety recommendations were made to the operator to address the safety issues.
Related Recommendations
develop and introduce a more intensive audit and assessment procedure for new train controllers for their first 12 months in the position, culminating in a re-certification after that period before moving into the bi-annual re-certification process.
do not allow train controllers to be re-certified unless they have undergone the required audits and assessments defined in Tranz Rail’s procedures within the prescribed timeframes.
as a matter of urgency make the use of signal blocking command “control tags” mandatory on signals controlling the entry of trains into sections occupied by HRVs, track maintenance gangs or other track users.
introduce self-appraisal techniques to assist train controllers in establishing their fitness to commence duty and provide adequate relief measures to ensure that train controllers do not feel obligated to commence duty if they do not consider they meet the required fitness standards.