Executive summary
At approximately 1010 hours on Thursday, 4 May 2000, Y35 shunt overran its track warrant limit at Mataura by 15 km. There was no opposing traffic.
Safety issues identified included:
• the need for better communication between train controllers and remote control operators when track warrants issued for main line shunts did not reflect work-between localities requested
• the need for more effective ways of communicating, and monitoring compliance with, amendments to rules and regulations to improve safety
• the need for formalised crew resource management training for Tranz Rail operational staff.
A safety action taken by Tranz Rail and 3 safety recommendations address these issues.
Related Recommendations
change the procedures for introducing rule and regulation amendments to ensure staff are fully conversant with such changes prior to introduction, and that effective introduction is monitored.
introduce the formalised crew resource management procedures recommended in safety recommendation number 001/99, and ensure that such procedures include remote-control operators operating main line shunts.
audit safety observation procedures to ensure defined frequencies are achieved, and ensure particular attention is given to newly certified staff.